ANALYSIS OF MEDICAL RESUME FILLING COMPLETENESS

AND THE ACCURACY OF CODING DIAGNOSES AGAINST

POTENTIAL RISKS OF BPJS CLAIMS AT INPATIENT
INSTALASI OF RS DR M HASSAN TOTO BOGOR IN 2018

Ernie Burhanuddin1, Soedarto Soepangat2, Rachmad3

1
Hospital Administration Study, Program Post Graduate Program at Respati Indonesia University.,
2
Department of Computing, Main University, MySecondTown, MyCountry
3

ernieburhanuddin65@gmail.com

Keywords: Medical resume, Coding, BPJS Claim

Abstract: This research discussed about medical resume completeness and the accuracy of coding diagnoses against
potential risks of BPJS claims at Inpatient Units of RS dr M Hassan Toto Bogor in 2018.
This research used mix method approach with cross sectional design.
This research found that there is still incompleteness in filling the medical record for secondary diagnostic
variables 8,5 %, the signature of in charge physician variable 10,5%, and supporting examination variable
1,6 %. Inaccuracy of coding diagnoses on primary diagnostic 28,2%, secondary diagnostic 6,4% and
procedur 6%. The risk of claims is delayed due to the incompleteness of medical resume amounting to Rp.
28.225.800,- in January,and obtained the difference in claims due to inaccuracy of Rp. 21.316.800,- in
February and Rp 20,909.900,- in March
The results suggested that socialization of standar operational procedur,coding practice, reward dan
punishment implementation, coding audit, coding team formulation, and continous evaluation by
management

1 INTRODUCTION pillars of health professionals, and pillars of

In line with President Jokowi - Jusuf Kalla's
vision and mission in the next five years, health is
a priority and the government's serious attention as
stated in Nawa Cita (9 priority agendas) in the fifth
item, "Improving the quality of human life of the
community" (Ministry of Health , 2015). And
health is one of the measures of human rights that
must be realized by each country (Declaration of
Human Rights, 1948). In line with the mandate of
Article 28 H paragraph (1) Amendments to the
Constitution of the Republic of Indonesia in 1945
have been stated that everyone has the right to
obtain health services. Article 34 paragraph (3)
states that the state is responsible for providing
health care facilities and appropriate public service
facilities.
The hospital is a system / part of the health
service system, has three pillars of authority, each
of which works autonomously but must be
coordinated in the system. (Djojosoegito, in Hatta
2008). These three pillars are the pillars of owners,
management. The three pillars each have a
hierarchy of power / authority, which has different
characteristics and characteristics. Harmony or
incompatibility between the three pillars
determines the success or failure of one hospital
mission. The harmony of the three pillars can be
achieved if there is openness, togetherness and
justice in the interaction of authority, and one of
the determining factors for the success of
harmonious interactions between the three
authorities is data and information.
Based on the Constitution and the SJSN Law
Number 40 of 2004 concerning the National Social
Security System (SJSN Law), the State through the
Ministry of Health has carried out health service
guarantees for the poor and disadvantaged through
the National Community Health Insurance
program (JAMKESMAS). Jamkesmas is a social
aid for health services for the poor and
disadvantaged whose contributions are paid by the
government and implemented since 2008.
 Efforts to control the quality and control of • Dependent variable potential risk of
the JKN program costs use the Indonesia Case hospital claims in the implementation of INA-
Base Groups tariff, which is then charged with the CBG's
INA CBG's tariff. The payment system with INA Qualitative data starts with searching medical
CBG's tariff is the amount of claim payments by record documents. The incomplete document will
BPJS Kesehatan to the Advanced Level Referral be traced to the relevant party which will then be
Health Facility (FKRTL) for a service conducted in-depth interviews. Then the
interpretation of data from the interview and
2 RESEARCH METHODS document search by the researcher will be
conducted Qualitative data analysis will find
This research is a mix method that uses detailed explanations about the reasons for
quantitative and qualitative research by designing a incomplete medical resumes and the inaccuracy of
cross sectional study, where the measurement on diagnosis codes
the subject is done once, aims to get an overview Bivariate analysis aims to see the effect of
of the distribution of the variables under study. The medical resume completeness as an independent
independent variables are the completeness of variable with the potential risk of hospital BPJS
medical resum filling and the accuracy of claims, depanden the first variable and also see the
diagnosis coding, the dependent variable is the influence of diagnosis coding accuracy as the
potential risk of claims from the hospital Dr. M second dependent, to see the effect is done by kai
Hassan Toto Bogor in the implementation of INA- squared test or Chi Square Test, where the degree
CBG. of trust (α) used is 0.05 (5%) and if the value of p
Qualitative research is a search for medical ≤ α value then there is a significance influence
resume documents which will then be carried out between the independent variables with the
in-depth interview techniques about factors and dependent variable or vice versa if the p value α
reasons that cause incompleteness of medical there is no influence .
resumes and inaccurate diagnostic coding.
The population in this study were all medical Gambar 1 Framework For Research Concept
record documents for inpatient installations in
January - April 2018, which were 400 documents. Completeness
Variable Of
Independent Variable Dependent
Medical Resume Filling
Primary data is obtained directly from the
medical resume file from January - April 2018. -Patient identity
Samples were carried radom obtained 200 medical -Physical examination
resume documents.
-Supporting investigation Potential Risk
Secondary data were obtained from reports of Of Hospital
BPJS patients treated in January - April 2018, and -Primary Diagnosis Bpjs Claim In
inpatient BPJS Claims Report for January - April Cbg's Ina
-Secondary Diagnosis
2018, as well as in-depth interviews with Implementatio
informants. -Therapy n
Quantitative data collected data will be
processed which aims to produce correct -Names and signatures of
doctorsDiagnosis
Koding who provide
information in accordance with the research services
Accuracy
objectives. Quantitative data processing is carried
out by univariate analysis. The analysis used to -Primary Diagnosis
describe the variables studied by creating a -Secondary Diagnosis
frequency distribution table, the data is presented -Procedure
in the form of a percentage. The analysis is used to
describe the frequency distribution and the
proportion of each of the variables studied,
namely:
• Independent variables (completeness of
medical resume filling and accuracy of diagnosis
coding)
3 RESEARCH RESULTS AND No Patient Identity Frequency Percentage

DISCUSSION 1 Complete 186 93 %

2 Incomplete 14 7%
3.1 Complete Description Of Medical
Resume 3 Total 200 100%

3.1.1 Patient Identity Variables Researchers analyzed the filling in of supporting

Tebel 1 : Distribution of completeness of medical investigations on medical resumes in part written
resume filling on variables Identity of Inpatient Patient on medical resumes, some of which did not write
Dr. M Hassan Toto Bogor Hospital January - April on the grounds of clinical discrepancies, and some
2018 assumed that there were attachments to the results
No Patient Identity Frequency Percentage so there was no need to write them down again.
1 Complete 200 100 % 3.1.4 Primary Diagnosis Variable
2 Incomplete 0 0% Tebel 4 : Distribution of completeness of medical
resume filling on variables
3 Total 200 100% primary diagnosis of Hospitalized Patients Dr. M Hassan
Toto Bogor Hospital January - April 2018
No Patient Identity Frequency Percentage
Researchers analyzed that the patient's identity in 1 Complete 200 100%
completing the medical resume completeness was
always filled in completely, because when 2 Incomplete 0 0%
registering for treatment the patient's identity label
was made and this patient's identity was also 3 Total 200 100%
included in one of the indicators of patient safety .
standards in accreditation namely the accuracy of Researchers analyzed the filling in of the primary
patient identification diagnosis on medical resumes had been done by all
physicians in charge of service providers, this was
3.1.2 Physical Examination Variables the same as the research conducted by Indriwanto
Tebel 2 : Distribution of completeness of medical (2014) which stated that for the primary diagnosis
resume filling on variables
100% filled
Physical Examination of Inpatient Patients Dr. M Hassan
Toto Bogor Hospital January - April 2018
No Patient Identity Frequency Percentage 3.1.5 Secondary Diagnosis Variables
Tebel 5 : Distribution of completeness of medical
1 Complete 191 95,5 % resume filling on variables
Secondary Diagnosis of Inpatients of Dr. M Hassan Toto
2 Incomplete 9 4,5 % Bogor Hospital January - April 2018
No Patient Identity Frequency Percentage
3 Total 200 100%
1 Complete 183 91,5 %

Researchers analyzed the filling of a physical 2 Incomplete 17 8,5 %

examination on a medical resume that had been
carried out by a doctor in charge of the patient
even though there were still those who did not
write on a medical resume.
3.1.3 Supporting variables
Tebel 3 : Distribution of completeness of medical
resume filling on variables
Physical Examination of Inpatient Patients Dr. M Hassan
Toto Bogor Hospital January - April 2018
3 Total 200 100%
Researchers analyzed the filling of secondary
diagnoses on medical resumes, mostly not filled in
8.5%, this was lower than researchers who had
previously done at Fatmawati Hospital by
Apriyantini Dewi (2015) stating that the secondary
diagnosis variable contained 39% incomplete.
From the results of interviewing filling in a
secondary diagnosis is a part that must be filled in
a medical resume, from the examination of the
completeness of the document writing a secondary 2 He difficulties in filling out the medical resume of
diagnosis there are still placement errors. inpatients is almost non-existent, the form has been
made and provided in the medical record, only the
"........ Written together with the main diagnosis."
doctor's compliance and responsibility for filling is not
(5) optimal. Following interview results:
This can potentially risk BPJS claims. "... Doctors often postpone filling out medical
documents." (4)
3.1.6 Therapy Variables "..... The doctor is too busy so there is no time to make."
Tebel 6 : Distribution of completeness of medical (3)
resume filling in Therapy variables
Inpatient patient Dr. M Hassan Toto Bogor Hospital 3 There is no reward and punishment for doctors in
January - April 2018 filling out medical resumes.
No Patient Identity Frequency Percentage "There are no, most specialist doctors are part time." (1)
"There has been no punishment if there are other
1 Complete 197 98,5 % hospitals that have implemented this, for example if a
doctor does not write a medical resume, he will be fined
2 Incomplete 3 1,5 % Rp. 100,000." (2)
"There doesn't seem to be any, it's the same as the
3 Total 200 100%
obedient and the disobedient." (3)

4 Evaluations have not been made by the management

Researchers analyzed filling variable therapy on of each unit related to the completeness of the medical
medical resumes partly written in medical resumes, resume.
some did not write this during the coding process "Supervision is less stringent, so if anyone does not fill
of course it could not be coded for diagnoses with out a medical resume because they are not reprimanded
no treatment so the file must be returned for then they will continue to do that ..." (3)
revision. The claim process is longer. "Evaluation has not been carried out, especially high
claims cases." (5)
3.1.7 Name Variables and Doctor Signs
Tebel 7 Distribution of completeness of medical resume 3.2. Accuracy of coding diagnosis
filling in name and Tebel 8 : Compatibility of primary diagnosis, secondary
Signature of Doctor of Inpatient Hospital Dr. M Hassan diagnosis and procedures in medical records vs. medical
Toto Bogor January - April 2018 resumes by doctors
No Patient Identity Frequency Percentage
Variables Amount (%)
1 Complete 198 99 %
corresponding it is not in
2 Incomplete 2 1% accordance with
3 Total 200 100% primary diagnosis 193 (96,5%) 7 (3.5 %)

Secondarydiagnosis 142 (71%) 5 8 (29 %)

“.......Often the name of the doctor in charge of the
patient is often not filled. Just signed because it's usually
stamped with a nurse "(2)
From the results of in-depth interviews, researchers got
several related things completeness of medical resume
including:
1 The Standard Operating Procedure (SPO) has not yet
been socialized, even though filling in a medical resume
is one thing that can cause disparity in writing a medical
resume.
"SPOs fill in medical resumes are there, only less
socialized." (1)
"The SPO is filling a medical resume with a dock
already." (4)
"I never knew the dock had an SPO." (2)
"... I have never heard of a dock, there should be, so it
hasn't been socialized." (5)
procedures 23 (74,2 %) 8 (25,8 %)
In coding the diagnosis of the results of the
study is done by comparing the filling of the main
diagnosis, secondary diagnosis, and the procedures
listed in the medical record and medical resume
filled by the doctor
Secondary diagnosis of many medical records is
not included in the medical resume.
Researcher Indriwanto (2014) completeness of
filling in secondary diagnoses is still not optimal
done by doctors in most hospitals, this is mostly
due to many factors of doctor's ignorance in
determining the diagnosis criteria are not yet clear Mon Wort Claim Pen Claim Not Amount
so it is not included in secondary diagnosis. th h (Rp) ding (Rp) Feas
Although the incompatibility of filling in the ible
main procedure (25.8%) is not as much as Janu 271 898.450 106 404.19 0 1.302.6
secondary diagnoses (29%), this is still very ary .700 9.100 49.800
important because it relates to the amount of
claims of INA CBG's Febr 285 826.447 57 230.98 0 1.057.4
uary .800 8.600 36.400
Tebel 9: Coding Diagnosis Accuracy in Main Diagnosis, Mar 392 1.145.2 41 161.99 0 1.307.2
Secondary Diagnosis and Procedure by Coder ch 87.000 7.400 84.400
Variables Amount (%)
Am 948 2.870.1 204 797.18 0 3.667.3
corresponding it is not in ount 85.600 5.100 70.600
accordance with
.
primary diagnosis 154 (77%) 46 (23%) Tebel 11: Reasons for Claiming Pending Period January
- March 2018
Secondarydiagnosis 102(51%) 98 (49%) No Cause Amount % Nominal (Rp)
procedures 54(72,97%) 20 (27%) 1 Card No. Not 15 7,35 41.210.400
suitable

The inaccuracy of coding in the main 2 No SEP Not 11 5,39 96.831700

diagnosis obtained a difference in claims of Rp. registered
31,072,800 (Data attachment 8). In the coding 3 Nursing Class Is 6 2,94 16.413.500
coding in INA CBG's software if the primary Not Appropriate
diagnosis is incomplete or not filled, the INA
CBG's tariff will not be issued, therefore the main 4 Confirm the 153 75 668.277.500
Primary
diagnosis greatly affects the rate that the hospital
Diagnosis and
will claim to the guarantor in this case BPJS. procedure
Inaccuracy of coding in secondary diagnosis
results in a difference in claims of Rp. 21,247,300 5 TXT Does not 19 9,31 61.600.000
(Data attachment 9). enter the BPJS
Inaccuracy of coding in the procedure will application
affect grouping and claims in the implementation AMOUNT 204 100 797.185.100
of CBG's INA. Inaccuracy in filling out the
procedure results in a claim difference of Rp.
18,910,800 (Data attachment 10)
Tebel 12: Claim Difference
3.3 Potential Risk Of Claim in Dr. H No Month Claim Difference (Rp)
Hassan Toto Bogor Hospital as
1 January 28.225.400
Implementation of INA CBG 's
2 February 21.316.800
Tebel 10: Analysis of inappropriate BPJS Claims at
Inpatient Installation 3 March 20.909.900
Hospital Dr. M Hassan Toto Bogor in 2018

The potential risk of claims that occur can be caused

by the process of filing a late claim. The researcher looks
at the process of filing a claim that should be done once
every month on the 5th to 10th of the following month.
Submitting a claim to the late BPJS is due to incomplete
Claim Analysis medical record file and the time to submit a late file.
The researcher conducted an observation on the flow
of the claim process that was carried out at Dr. M Hassan
Toto Hospital in Bogor and found that it was related to
the number of human resources (HR). The number of concluded that there are significant differences between
coder staff to coding inpatients at Dr. M Hassan Toto the proportion of potential risk of BPJS claims between
Bogor Hospital is currently only one (1) person and this complete and incomplete medical record files, where a
serves as an internal verifier as well, resulting in the complete medical record file there is no risk for potential
claim process being slow / long. Not to mention the BPJS claims
DPJP who often postpone filling out medical resumes.
Tebel 14: Effect of Accuracy in Diagnosing Coding
with BPJS Claim Risk potential
Accuracy Risk Potential Of Bpjs
3.4 Bivariat Analysis Of Coding Claim
N Diagnosis Total
The aim is to determine the effect of o
Yes No
independent variables and dependent variables and
n % n % n %
to see the existence of significant differences with
the Chi Square test approach used. 1 Complete 5 2,5 165 82,5 170 85
Data processing is done by calculating the
formula for Chi Square statistical test, where the 2 Not 27 13, 3 1,5 30 15
degree of trust (α) used is 0.05 (5%) and at p ≤ complete 5
value α means that there is a significant difference
Total 32 16 168 84 200 100
between the potential risk of BPJS claim and the
independent variable (Completeness Medical X = 102,493, p- (value) = 0,000
Resume and Accuracy of Coding Diagnosis) and
vice versa.. Based on the results of chi square statistical tests
with the results of the p-value = 0,000 means that the
Tebel 13: Effect of Completeness of filling in Medical value of p ≤ α value (0.05), it can be concluded that there
Resumes with BPJS Claim Risk potential are significant differences between the proportion of
Completenes Risk Potential Of potential risk claims BPJS and the appropriate and
s Of Medical Bpjs Claim incorrect medical record file in the accuracy of coding a
N Total diagnosis where an inappropriate medical record file has
Resume
Yes No a greater risk of potential BPJS claims
o Filling
The inaccuracy in the diagnosis coding in this file is
n % n % n % because it is still in one group in the CBG INA. the risk
1 Complete 7 3,5 12 60 12 63,5 of BPJS claims between proper and incorrect medical
0 7 record files in the accuracy of coding diagnosis, where
medical record files that are inappropriate in diagnosis
2 Not complete 54 27 19 9,5 73 36,5 coding are at risk for potential BPJS claims.
Total 61 30, 13 69, 20 100
5 9 5 0 4 CONCLUSION
From the results of the research conducted with
X = 102,493, p- (value) = 0,000 the title of research analysis
From the results of chi square statistical test the
Completeness of Filling in Medical Resumes and
effect of completeness of medical resume filling with the Accuracy of Diagnosis Coding on the Potential
potential risk of BPJS claims obtained results p-value = Risks of BPJS Claims in Inpatient Installation of
0,000 means that the value of p ≤ α value (0.05) then it Dr.. M. Hassan Toto Bogor in 2018 can be
can be concluded that there are significant differences concluded as follows:
between the proportion of potential risk of BPJS claims
between record files complete and incomplete medical 1.Completeness of filling out a medical resume in
treatment where incomplete medical record files have a the inpatient room of Dr. M. Hassan Toto Bogor
greater risk on potential BPJS claims. The still found problems. Incomplete medical resume
incompleteness of this file is in the patient's address or filling is found in variables
the patient is sent from the polyclinic / IGD does not •Physical examination of 4.5%,
affect the outcome of the claim. •Investigation of 7%
And based on the results of the chi square statistical •Secondary diagnosis of 8.5%,
test with the results of the number p-value = 0,000 •Therapy 1.3% and
means that the value of p ≤ α value (0.05) then it can be
 •The name and signature of the doctor
responsible for the patient is 1%.
This is because there are still many DPJP who do
not write medical resumes according to their rules,
Standard Operating Procedures (SPO) which have
not been implemented optimally, the absence of
continuous socialization of Operational Procedure
Standards (SPO), the absence of reward and
punishment, facilities and infrastructure and
behavioral factors doctor's compliance is still low
and there is no evaluation by management.
2.In the filling of the coding by the coder still
found inaccuracy. This inaccuracy is found in
•Primary diagnosis (23%),
•Secondary diagnosis (49%) and
• Procedure (27%)
This is due to the writing of the main diagnosis the
doctor should see at the end of the episode of
treatment or at a further examination can also be
taken from the main symptoms, the results of
abnormal investigations. . Writing a diagnosis and
procedure must be clear and detailed, it should not
be short because it will affect the coding when the
coder enters into the INA-CBG's software
3.Potential risk of claims that exist in Dr. M
Hassan Toto Bogor Hospital is
-The process of filing a late claim is due to the
limited number of human resources in this case the
coder, to code inpatient services at this time only
one (1) person and also served as an internal
verifier, its coding ability is still lacking. Not to
mention the DPJP who often postpone filling out
medical resumes.
-Diagnosis mismatches and coding inacbg’s
curacies cause claims to be suspended and when
re-filing occurs Rp. 28,225,400 in January, Rp.
21,316,800 in February and Rp. 20,909,900 in
March. Surely this will affect hospital cash flow
Statistical test results between the influence of
completeness of filling in medical resumes with
potential risk of BPJS claims were found to be
significant differences (p-value = 0,000) as well as
between the influence of accuracy of diagnosis
coding and potential risk of BPJS claims (p-value
= 0,000)
5 SUGGESTION
1.In order to complete the medical resume filling
complete
•Re-conduct the socialization of the Operational
Procedure Standards (SPO) that already exist about
filling in the correct medical resume and this must
be carried out optimally and continuously.
•Monitoring and evaluation of filling out medical
record forms regularly
•Implementing a reward and punishment system
2.Inaccuracy in coding can be done with
•Improvement of employee competence in the
form of coding training for existing coding
personnel on an ongoing basis both internally and
externally
•Submitting additional human resources for coding
power as needed at Dr. M Hassan Toto Bogor
Hospital
•Making policies about the limitations of
secondary diagnoses and socializing the DPJP
during medical committee meetings
•Adding books or a list of diagnostic codes that are
adjusted to the code in the INA-CBGs software so
as to minimize coding mismatches, both primary
diagnoses, secondary diagnoses and procedures.
3.To minimize or prevent potential risks from Dr.
M Hassan Toto Bogor Hospital
•Reactivate the existing casemix team, which
handles claims administration, coding, receipt of
claims, verification and evaluation of claims by
renewing the Decree (SK) from the Head of the
Hospital, and being rewarded in the form of
services or honorarium.
•Implementation of a health information
technology system integrated in each service unit.
•Continuous socialization policy regarding SPO
Medical resume in the implementation of INA-
CBG's must be made by the head of the dr. M.
Hassan Toto Bogor
Further research needs to be done specifically
about the accuracy of coding diagnosis, claim
management in the application of INA-CBG
applications and their impact on hospitals with
problem solving that can be done.
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