The Completeness and Accuracy of Hepatoma Coding for Medical Procedure Based on ICD-9 CM at Public Hospital in Padang

Background: Hepatoma  or  hepatocellular  carcinoma  (KHS)  is  a  primary  malignant  tumor  of  the  liver originating from hepatocytes and the 3rd cause of death from cancer in the world. The history of a hepatoma patient can be seen based on the patient's medical record. The filling of medical record is done by doctors, nurses and medical record personel. However, in medical record  filling, incompleteness  is often found and cause inaccurate information. Accuracy coding important for financial of hospital.Methods: Type  of  research  is  quantitative  descriptive,  which  is  to  determine  the  completeness  and accuracy of  the  medical  records  for  hepatoma  cases and procedure code using criteria  for  document  quantitative  analysis in a public hospital, Padang. The study  design  used  a  retrospective  analytical  approach. The variables in the study were completeness of discharge summary and accuracy of hepatoma procedure based on ICD-9 CM. The population in this study were inpatient medical record documents for Hepatoma cases at a public hospital, Padang from June to August 2019, which were 45 medical record documents (discharge summary form) of hepatoma inpatients.Results: From 45 hepatoma patient medical record documents, filling of item name, medical record number, date of admission, indication of the patient being treated, history, physical examination, diagnostic examination, procedures, medications given, medicines used at home, PPBS doctor's signature, DPJP doctor's hand is complete 100% . Highest incompleteness of filling was found  at code ICD (47%) and address item (43%). From 45 discharge summary , accuracy procedure code at hepatome case shows 100 % accurate in ultrasonoggrafi abdomen and ultrasonografi thorax. While that EKG 98% accurate and 95 % rontgen thorax.Conclusions: In general, item data of discahrege summary for hepatoma medical record are completenes; highest incompleteness of filling was found  at code ICD (47%) and address item (43%); Accuracy of code procedure more than 90% in each code procedure.