Factors Influencing The Accuracy Of Disease Diagnosis Coding Based On Icd-10 At A Community Health Center

Abstract

Medical records are an important source of information in healthcare services, one of which is through the accuracy of writing disease diagnosis codes. The accuracy of diagnosis coding greatly determines data quality, service quality, and the smooth process of health cost claims. However, in practice, errors in writing codes are still frequently found, which can reduce the accuracy of medical information. This study aims to identify the factors influencing the accuracy of writing disease diagnosis codes based on ICD-10 at a community health center. The type of research used is descriptive qualitative with a case study design. The research subjects consisted of medical record officers, doctors, and the head of medical records, while the research objects were 85 outpatient medical record files. Data collection techniques were carried out through observation, interviews, and documentation studies using interview guidelines and observation checklists as instruments. The results of the study showed that out of 80 medical record files examined, 42 files (52.5%) had accurate diagnosis codes, while 38 files (47.5%) were inaccurate. The factors influencing the accuracy of diagnosis coding in terms of the 5M aspects are: (1) Man, officers did not use the ICD-10 Book in searching for diagnosis codes but instead relied on the internet or Google; (2) Material, the printed ICD-10 book was not available in the medical record room; (3) Machine, computers were available but constrained by internet network issues; (4) Money, there was no budget allocation for procuring community health center is still low. It is necessary to improve staff competencies through training, provide adequate facilities, and develop SOPs so that coding accuracy in accordance with ICD-10 standards can be achieved.