ANALYSIS OF MEDICAL RESUME FILLING COMPLETENESS

AND THE ACCURACY OF CODING DIAGNOSES TOWARDS

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

Ernie Burhanuddin1, Soedarto Soepangat2, Rachmad3

1 Hospital Administration Study, Post Graduate Program at Respati Indonesia University,Indonesia

ernieburhanuddin65@gmail.com

Keywords: Medical resume, Coding, BPJS Claim

Abstract: This research examined medical resume completeness and the accuracy of coding diagnoses towards
potential risks of BPJS claims at Inpatient Units in RS dr M Hassan Toto Bogor in 2018.
This research employed the mix method approach with cross sectional design.
This research revealed that incompleteness is prevalent in the medical record filling in the following
variables: 8.5% for secondary diagnostic, 10.5% for the signature of in charge physician, and 1.6 % for
supporting examination. Inaccuracy of coding diagnoses on primary diagnostic was found at 28.2%,
meanwhile secondary diagnostic was found at 6.4% and procedur at 6%. The risk of delayed claims due to
the incompleteness of medical resume reached Rp. 28.225.800,- in Januar. It was found that the difference
in claims due to inaccuracy was Rp. 21.316.800,- in February and Rp 20,909.900,- in March.
From these results, it can be suggested that a socialization of the standard operational procedure should be
conducted, as well as coding practice, reward dan punishment implementation, coding audit, coding team
formulation, and continuous evaluation by management.

1 INTRODUCTION the health professionals, and the management.

In line with President Jokowi - Jusuf Kalla's
vision and missionfor the next five years, health is
a priority. Hence, the government's serious
attention can be found in the fifth item of Nawa
Cita (9 priority agendas) which stated "Improving
the quality of human life of the community"
(Ministry of Health , 2015). Health also is one of
the measures of human rights that must be realized
by each country (Declaration of Human Rights,
1948). The mandate of Article 28 H paragraph (1)
Amendments to the Constitution of the Republic of
Indonesia in 1945 also made it clear that everyone
has the right to obtain health services. Furthermore,
Article 34 paragraph (3) stated that the state is
responsible for providing health care facilities and
appropriate public service facilities.
The hospital is a system or part of the health
service system with 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 owners,
Each of the three pillars has a hierarchy of power
or authority with different characteristics.
Harmony or incompatibility between the three
pillars determines the success or failure of a
hospital mission. The harmony of the three pillars
can be achieved if there is openness, togetherness
and justice in the interaction of authority. Thus,
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 NSSS
(National Social Security System) Law Number 40
of 2004 concerning the National Social Security
System (SJSN Law), the State through the Ministry
of Health has carried out health services which
guarantees inclusivity 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 has been
implemented since 2008.
 Efforts to control the quality and the the JKN
program costs itself use the Indonesia Case Base
Groups tariff, which is then charged with the INA
CBG's tariff. The payment system with INA CBG's
tariff is the amount of claim payments by BPJS
Kesehatan to the Advanced Level Referral Health
Facility (FKRTL) for a service
2 RESEARCH METHODS
This research was a mix method which
combines the quantitative and qualitative research
and employed a cross sectional design study, in
which the measurement on the subject is done
once. It was aimed to get an overview of the
distribution of the variables used in the study. The
independent variables were the completeness of
medical resume filling and the accuracy of
diagnosis coding. On the other hand, the dependent
variable was the potential risk of claims from the
hospital Dr. M Hassan Toto Bogor in the
implementation of INA- CBG.
Qualitative research method was employed to
conduct an examination in medical resume
documents which was carried out in-depth
interview techniques. The factors and reasons that
cause incompleteness of medical resumes and
inaccurate diagnostic coding was discussed in the
interview.
The population in this study were all the
medical record documents for inpatient unit in
January - April 2018, which were 400 documents.
The primary data was obtained directly
from the medical resume file from January - April
2018. Sampling process was carried in random
sampling method in which 200 medical resume
documents were obtained.
The secondary data were obtained from the
reports of BPJS patients treated in January - April
2018, as well as the inpatient BPJS Claims Report
for January - April 2018. In-depth interviews with
informants were also conducted to support these
data
The quantitative data collected was processed
to produce correct information in accordance with
the research objectives. Quantitative data
processing was carried out with univariate analysis.
The analysis was used to describe the variables by
creating a frequency distribution table, in which
the data was presented in the form of percentage.
The analysis was employed to describe the
frequency distribution and the proportion of each
of the variables studied, which were:
• The independent variables (the
completeness of medical resume filling and the
accuracy of diagnosis coding)
• The dependent variable (potential risk of
hospital claims in the implementation of INA-
CBG's).
The qualitative data collection process started
with searching medical record documents. The
incomplete document was traced to the relevant
party with which then in-depth interviews were
conducted. Then, the interpretation of data from
the interview and the documents found by the
researcher were processed in qualitative data
analysis in which detailed explanations about the
reasons for incomplete medical resumes and the
inaccuracy of diagnosis codes were closely
examined.
The bivariate analysis was aimed to reveal the
effect of medical resume completeness as an
independent variable with the potential risk of
hospital BPJS claims, as the first dependent
variable, as well as the influence of diagnosis
coding accuracy as the second dependent variable.
In order to to examined these effects, kai squared
test or Chi Square Test was conducted. The degree
of trust (α) used was 0.05 (5%) and if the value of
p ≤ α value significance influence between the
independent variables with the dependent variable
or vice versa if the p value α there is no influence .
Gambar 1 Framework For Research Concept
Variable Independent Variable Dependent
Completeness Of
Medical Resume Filling
-Patient identity
-Physical examination Potential Risk
-Supporting investigation Of Hospital
-Primary Diagnosis Bpjs Claim In
Cbg's Ina
-Secondary Diagnosis
-Therapy Implementation
-Names and signatures of
doctors who provide
Coding Diagnosis
Accuracy
-Primary Diagnosis
-Secondary Diagnosis
-Procedure
3 RESEARCH RESULTS AND No Patient Identity Frequency Percentage

DISCUSSION 1 Complete 186 93 %

3.1 Complete Description Of Medical 2 Incomplete 14 7%

Resume 3 Total 200 100%

3.1.1 Patient Identity Variables

Table 1 : Distribution of completeness of medical Researchers analyzed that the filling in of
resume filling on variables Identity of Inpatient Patient supporting investigations on medical resumes were
Dr. M Hassan Toto Hospital Bogor January - April 2018 in part written on medical resumes, some of which
No Patient Identity Frequency Percentage was not written on the grounds of clinical
discrepancies, and some assumed that there were
1 Complete 200 100 % attachments to the results so there was no need to
write them down again.
2 Incomplete 0 0%

3 Total 200 100% 3.1.4 Primary Diagnosis Variable

Tebel 4 : Distribution of completeness of medical
resume filling on variables
primary diagnosis of Hospitalized Patients Dr. M Hassan
Researchers found that the patient's identity was Toto Bogor Hospital January - April 2018
always filled in completely in the medical resume. No Patient Identity Frequency Percentage
It may be because when registering for treatment,
the patient's identity label was made and patient's 1 Complete 200 100%
identity included in one of the indicators of patient
safety standards in accreditation specifically the 2 Incomplete 0 0%
accuracy of patient identification
3 Total 200 100%
3.1.2 Physical Examination Variables
Table 2 : Distribution of completeness of medical
resume filling on variables Physical Examination of Researchers analyzed that the filling in of the
Inpatient Patients in Dr. M Hassan Toto Hospital Bogor primary diagnosis on medical resumes was done by
January - April 2018 all physicians in charge of providing service, this
No Patient Identity Frequency Percentage was in line with the research conducted by
Indriwanto (2014) which also revealed the primary
1 Complete 191 95.5 % diagnosis field was filled 100%.
2 Incomplete 9 4.5 %
3.1.5 Secondary Diagnosis Variables
Tebel 5 : Distribution of completeness of medical
3 Total 200 100%
resume filling on variables Secondary Diagnosis of
Inpatients of Dr. M Hassan Toto Hospital Bogor January
- April 2018
Researchers revealed that the filling of a physical No Patient Identity Frequency Percentage
examination on a medical resume was carried out
by a doctor in charge of the patient. However, 1 Complete 183 91,5 %
there were still those who did not write on a
medical resume. 2 Incomplete 17 8,5 %

3 Total 200 100%

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 Hospital Bogor
January - April 2018
Researchers found that the filling of secondary
diagnoses on medical resumes was mostly not
filled in (8.5%). This result was lower than
previous research done at Fatmawati Hospital by
Apriyantini Dewi (2015) which stated that the
secondary diagnosis variable contained 39%
incompleteness.
From the results of the interviews filling in a
secondary diagnosis is a part that must be filled in
a medical resume. However, from the examination
of the completeness of the secondary diagnosis
document, placement errors were still found.
"........ Written together with the main diagnosis."
(5) can potentially risk BPJS claims.
3.1.6 Therapy Variables
Tebel 6 : Distribution of completeness of medical
resume filling in Therapy variables Inpatient patient Dr.
M Hassan Toto Hospital Bogor January - April 2018
No Patient Identity Frequency Percentage
1 Complete 197 98,5 %
2 Incomplete 3 1.5 %
3 Total 200 100%
Researchers analyzed the filling variable therapy
on medical resumes. It was found that the field was
partly written in medical resumes. However, some
did not write this during the coding process.
Therefore, it could not be coded for diagnoses with
no treatment thus the file must be returned for
revision. The claim process was longer.
3.1.7 Name Variables and Doctor Signs
Tebel 7 Distribution of completeness of medical resume
filling in name and Signature of Doctor of Inpatient
Hospital Dr. M Hassan Toto Bogor January - April 2018
No Patient Identity Frequency Percentage
1 Complete 198 99 %
2 Incomplete 2 1%
3 Total 200 100%
“.......Often the name of the doctor in charge of the
patient is not filled. Just signed because it's usually
stamped in by a nurse "(2)
From the results of in-depth interviews, researchers
found several things related to completeness of medical
resume including:
1 The Standard Operating Procedure (SOP) has not yet
been socialized, even though filling in a medical resume
is of the factors 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)
2 The difficulties in filling out the medical resume of
inpatients was almost non-existent because the form has
been made and provided in the medical record, only the
doctor's compliance and responsibility for filling is not
optimal. The following were interview results:
"... Doctors often postpone filling out medical
documents." (4)
" The doctor is too busy so there is no time to make."
(3)
3 There was no reward nor punishment for doctors in
filling out medical resumes.
"There are none, most specialist doctors are part time."
(1) "There has been no punishment if there are other
hospitals that have implemented this, for example if a
doctor does not write a medical resume, he will be fined
Rp. 100,000." (2)
"There doesn't seem to be any, it's the same as the
obedient and the disobedient." (3)
4 Evaluations have not been made by the management
of each unit related to the completeness of the medical
resume.
"Supervision is less stringent, so if anyone does not fill
out a medical resume because they are not reprimanded,
then they will continue to do that " (3)
"Evaluation has not been carried out, especially in high
claims cases." (5)
3.2. Accuracy of coding diagnosis
Tebel 8 : Compatibility of primary diagnosis, secondary
diagnosis and procedures in medical records vs. medical
resumes by doctors
Variables Amount (%)
corresponding it is not in
accordance with
primary diagnosis 193 (96,5%) 7 (3.5 %)
Secondarydiagnosis 142 (71%) 8 (29 %)
procedures 23 (74,2 %) 8 (25,8 %)
In coding the diagnosis of the results, a
comparison of the filling of the main diagnosis,
secondary diagnosis, and the procedures listed in
the medical record and medical resume filled by
the doctor was done.
Secondary diagnosis of numerous medical
records was not included in the medical resume.
Indriwanto (2014) found that completeness of
filling in secondary diagnoses is still not optimally
done by doctors in most hospitals. This was mostly Claim Analysis
due to many factors, such as the doctor's ignorance
Mon Wort Claim Pen Claim Not Amount
in determining because the diagnosis criteria were th h (Rp) ding (Rp) Feas
not yet clear so it was not included in secondary ible
diagnosis.
Although the incompatibility of filling in the Janu 271 898.450 106 404.19 0 1.302.6
main procedure (25.8%) was not as prevalent as ary .700 9.100 49.800
the secondary diagnoses (29%), this is still very
Febr 285 826.447 57 230.98 0 1.057.4
important because it is related to the amount of
uary .800 8.600 36.400
claims of INA CBG's
Mar 392 1.145.2 41 161.99 0 1.307.2
Tebel 9: Coding Diagnosis Accuracy in Main ch 87.000 7.400 84.400
Diagnosis, Secondary Diagnosis and Procedure by
Coder Am 948 2.870.1 204 797.18 0 3.667.3
Variables Amount (%) ount 85.600 5.100 70.600

corresponding it is not in .
accordance with Tebel 11: Reasons for Claiming Pending Period January
- March 2018
primary diagnosis 154 (77%) 46 (23%) No Cause Amount % Nominal (Rp)

Secondarydiagnosis 102(51%) 98 (49%) 1 Card No. Not 15 7,35 41.210.400

suitable
procedures 54(72,97%) 20 (27%)
2 No SEP Not 11 5,39 96.831700
registered
On the inaccuracy of coding in the main
3 Nursing Class Is 6 2,94 16.413.500
diagnosis a difference in claims was found, Not Appropriate
amounted to Rp. 31,072,800 (Data attachment 8).
In the codes in INA CBG's software it as found 4 Confirm the 153 75 668.277.500
that if the primary diagnosis is incomplete or not Primary
filled, the INA CBG's tariff will not be issued. Diagnosis and
Therefore, the main diagnosis actually greatly procedure
affects the rate of the hospital claim to the
5 TXT Does not 19 9,31 61.600.000
guarantor which was BPJS in this case . enter the BPJS
The inaccuracy of coding in secondary application
diagnosis results in a difference in claims of Rp.
21,247,300 (Data attachment 9). AMOUNT 204 100 797.185.100
Inaccuracy of coding in the procedure affect
grouping and claims in the implementation of
CBG's INA. Inaccuracy in filling out the procedure
Tebel 12: Claim Difference
resulted a claim difference of Rp. 18,910,800 (Data
No Month Claim Difference (Rp)
attachment 10)
1 January 28.225.400
3.3 Potential Risk Of Claim in Dr. H
Hassan Toto Hospital Bogor as 2 February 21.316.800
Implementation of INA CBG 's
3 March 20.909.900
Tebel 10: Analysis of inappropriate BPJS Claims at
Inpatient Unit Dr. M Hassan Toto Hospital Bogor in 2018
The potential risk of claims can be caused by the a late
claim filling process. The researchers looked 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 late claim to BPJS was caused by greater risk potential on BPJS claims. The
incomplete medical record file and the time it took to incompleteness in the patient's address or if the patient is
submit a late file. sent from the polyclinic / IGD does not affect the
The researcher conducted an observation on the flow outcome of the claim.
of the claim process carried out at Dr. M Hassan Toto Furthrmore, based on the results of the chi square
Hospital in Bogor and found that it was related to the statistical test it was found that p-value = 0,000 which
number of human resources (HR). The number of coder meant that the value of p ≤ α value (0.05). Therefore, it
staff to coding inpatients at Dr. M Hassan Toto Bogor can be concluded that there was a significant difference
Hospital is currently only one (1) person and who also in the proportion of potential risk of BPJS claims
serves as an internal verifier as well, which resulted in between complete and incomplete medical record files,
the claim process being slow / long. This did not include wherein a complete medical record file possess no
the DPJP who often postpone filling out medical potential risk for BPJS claims
resumes.
Tebel 14: Effect of Accuracy in Diagnosing Coding
with BPJS Claim Risk potential
3.4 Bivariate Analysis Accuracy Risk Potential Of Bpjs
Of Coding Claim
N Diagnosis Total
The aim of this analysis was to determine the
o Yes No
effect of independent variables and dependent
variables as well as to see the existence of n % n % n %
significant differences with the Chi Square test
approach. 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 was 0.05 (5%). At p ≤ complete 5
value α it means that there was a significant
difference between the potential risk of BPJS claim Total 32 16 168 84 200 100
and the independent variable (Completeness
X = 102,493, p- (value) = 0,000
Medical Resume and Accuracy of Coding
Diagnosis) and vice versa. Based on the results of chi square statistical tests p-
value = 0,000 was found which signified the value of p ≤
Tebel 13: Effect of Completeness of filling in Medical α value (0.05). It can be concluded that there was a
Resumes with BPJS Claim Risk potential significant difference between the proportion of potential
Completenes Risk Potential Of risk claims BPJS and the appropriate and incorrect
s Of Medical Bpjs Claim medical record file with the accuracy of coding a
N Resume Total diagnosis. An inappropriate medical record file has a
o Filling Yes No greater risk of potential BPJS claims
The inaccuracy in the diagnosis coding in this file is
n % n % n % caused by a one group policy in the CBG INA. There is
1 Complete 7 3,5 12 60 12 63, a risk in BPJS claims between proper and improper
0 7 5 medical record files in the accuracy of coding diagnosis,
where improperly filled medical record files in diagnosis
2 Not complete 54 27 19 9,5 73 36, coding are at potential risk BPJS claims.
5

Total 61 30, 13 69, 20 100

4 CONCLUSION
5 9 5 0 From the results of the research titled analysis
Completeness of Filling in Medical Resumes and
X = 102,493, p- (value) = 0,000 Accuracy of Diagnosis Coding on the Potential
Risks of BPJS Claims in Inpatient Installation of
From the results of chi square statistical test, it was Dr.. M. Hassan Toto Hospital Bogor in 2018, the
found that the effect of completeness of medical resume following conclusion can be concluded:
filling with the potential risk of BPJS claims obtained
the results p-value = 0,000 which meant that the value of
p ≤ α value (0.05). Therefore it can be concluded that
there was a significant difference in the proportion of
potential risk of BPJS claims between the complete and
incomplete record files in medical treatment. An
incomplete medical record files have a
1. Problems were exhibited in completeness in
filling out a medical resume in the inpatient unit of
Dr. M. Hassan Toto Hospital Bogor problems.
Incomplete medical resume filling was found in
the following variables:
• Physical examination at 4.5%,
• Investigation at 7%
• Secondary diagnosis at 8.5%,
• Therapy at 1.3% and
• The name and signature of the doctor
responsible for the patient was at 1%.
This problem was caused by many DPJP who do
not write medical resumes according to the rules,
the Standard Operating Procedures (SOP) which
have not been implemented optimally, and the
absence of continuous socialization of Operational
Procedure Standards (OPS), as well as the absence
of reward and punishment, facilities and
infrastructure and the behavioral factors of doctor's
compliance, and no evaluation by management.
2. In the filling of the coding by the coder,
inaccuracies were still found. These inaccuracies
was found in:
• Primary diagnosis (23%),
• Secondary diagnosis (49%) and
• Procedure (27%)
This was due to the filling in of the main diagnosis
in which the doctor should observe the end of the
treatment series or at the possibility of further
examination based on the main symptoms and the
results of abnormal investigations. Filling in a
diagnosis and procedure must be done in a clear
and detailed manner. 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 Hospital Toto Bogor were found in
-The process of filing a late claim due to the
limited number of human resources, in this case the
coder who code inpatient services. At this time
there was only one (1) person who at the same time
also served as an internal verifier and whose
coding ability is still lacking. Not to mention the
DPJP who often postpone filling out medical
resumes.
-Diagnosis mismatches and coding inacbg’s
inacuracies cause claims to be suspended and re-
filing occurs at 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
Significant differences were found in statistical
test results on the influence of completeness of
filling in medical resumes with potential risk of
BPJS claims at (p-value = 0,000) as well as
between the influence of accuracy of diagnosis
coding and potential risk of BPJS claimswhere (p-
value = 0,000)
5 SUGGESTION
1. In order to complete the medical resume :
• Re-conduct the socialization of the Operational
Procedure Standards (OPS) that is already exist on
the filling in the appropriate medical resume which
this must be carried out optimally and
continuously.
• Monitoring and evaluating the filling out process
of medical record forms regularly
• Implementing a reward and punishment system
2. Inaccuracy in coding can be addressed with
• Improvement of employee competence in the
form of coding training for existing coding
personnel on a regular basis both internally and
externally
• Adding an additional human resource personnel
for coding as it evidently needed at Dr. M Hassan
Toto Hospital Bogor
• 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 to
minimize coding mismatches in both primary
diagnoses, secondary diagnoses and procedures.
3. To minimize or prevent potential risks from Dr.
M Hassan Toto Hospital Bogor
• 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.
• Implement an integrated health information
technology system in each service unit.
• Do a continuous socialization of policy regarding
SPO Medical resume in the implementation of
INA- CBG's by the head of the dr. M. Hassan Toto
Hospital Bogor
Further research specifically on the accuracy of
coding diagnosis, claim management in the
application of INA-CBG applications and their
impact on hospitals is critical, preferably with
problem solving.
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