Analysis of the Accuracy of the Fourth Character ICD-10 Diagnostic Code on Patients' Medical Records in Support of INA-CBG's Payment System

Abstract

The accuracy of ICD-10 fourth-character diagnosis coding plays an important role in producing valid health data and supporting the healthcare payment system under the INA-CBG’s payment system. The fourth character provides more detailed specifications of a diagnosis, thereby improving the accuracy of disease classification, producing more accurate clinical information, and supporting accurate case grouping and healthcare financing. This study aimed to analyze the accuracy of ICD-10 fourth-character diagnosis coding in patient medical records at Faga Husada General Hospital. This study employed a descriptive quantitative method with a sample of 89 inpatient medical record files. Data were collected through observation and interviews. The results showed that 68 medical record files (76.4%) had accurate diagnosis codes, while 21 files (23.6%) had inaccurate diagnosis codes. The most common coding error was the Non-Specific Code (NSC), found in 19 files (90.5%), followed by the Inappropriate Code (IC), found in 2 files (9.5%). Factors affecting coding inaccuracy included human resources, standard operating procedures (SOPs), documentation, and supporting facilities. The study concluded that most ICD-10 fourth-character diagnosis coding at Faga Husada General Hospital was accurate; however, inaccuracies in the diagnosis coding process were still found.