Presentasi yang saya bawakan dalam pelatihan "Strategi Penggunaan ICD-10 dan ICD-9 CM dalam Mendukung BPJS" yang diadakan oleh RS Panti Nugroho, Sabtu, 8 Mei 2014. Semoga bermanfaat.

1. Medical Record for DRG/
CBG Coding Purpose
dr.
Robertus
Arian
D.
Head
of
Emergency
Dept.
Panti
Rapih
Hospital
http://www.jacksongeneral.com

2. Topics
• Literature
Review
• Medical
Record
Files
• Problems
• Fraud
• Conclusion
http://i.livescience.com

3. Learning from Thailand (1) - Results
• Hospital
providers
should
not
be
assumed
capable
of
producing
high
quality
DRG
codes,
especially
in
resource-­‐
limited
settings.
• …
variation
in
hospital
coding
practices
in
an
under-­‐
resourced
health
system
is
another
major
determinant
of
DRG
coding
quality.
• It
was
not
fair
for
a
hospital
to
be
assumed
‘capable’
of
producing
good
codes
without
qualified
physicians
and/or
coders.
• …
the
use
of
software,
number
of
medical
statisticians,
and
experience
of
physicians
seemed
to
be
the
most
important.
Pongpirul
K,
Walker
DG,
Rahman
H,
Robinson
C;
DRG
coding
practice:
a
nationwide
hospital
survey
in
Thailand;
BMC
Health
Services
Research
2011,
11:290

4. Learning from Thailand (2) –Hosp. Intention
• FACTOR
1
–
Data
Quality
• Audit
• Improvement
http://images.amari.com
• FACTOR
2
–
Coding
Practice
• Physician
responsible
• Incentive
/
punishment
• Career
pathway
for
medical
statistician
• FACTOR
3
–
Reimbursement
• DRG
seeker
software
• Various
combinations
of
codes
entered
• Swap
principal
and
secondary
diagnoses
Pongpirul
K,
Walker
DG,
Rahman
H,
Robinson
C;
DRG
coding
practice:
a
nationwide
hospital
survey
in
Thailand;
BMC
Health
Services
Research
2011,
11:290

5. Pongpirul
K,
Walker
DG,
Winch
PJ,
Robinson
C;
A
qualitative
study
of
DRG
coding
practice
in
hospitals
under
the
Thai
Universal
Coverage
Scheme
;
BMC
Health
Services
Research
2011,
11:71

6. Thailand vs Indonesia
• Discharge
Summarization.
Clinical
data
in
medical
records
are
used
to
fill
out
the
discharge
summary.
The
physician
responsible
for
the
patient
is
considered
the
best
person
for
this
task.
• Completeness
Checking.
This
step
is
to
check
the
completeness
of
the
medical
record
and
discharge
summary.
Charts
with
incomplete
clinical
data
will
be
returned
to
the
responsible
physician
for
correction.
• Diagnosis
and
Procedure
Coding.
The
hospital
coder
assigns
the
ICD-­‐10
code
and
ICD-­‐9-­‐CM.
Should
there
be
any
missing
or
questionable
information
in
the
discharge
summary
or
medical
record,
the
coder
will
inform
the
responsible
physician,
who
may
or
may
not
agree
to
revise.
• Relative
Weight
Challenging.
• Coding
Report.
Pongpirul
K,
Walker
DG,
Winch
PJ,
Robinson
C;
A
qualitative
study
of
DRG
coding
practice
in
hospitals
under
the
Thai
Universal
Coverage
Scheme
;
BMC
Health
Services
Research
2011,
11:71

7. About Discharge Summary (1)
• “…
the
Medical
Records
are
not
documented
properly
in
the
university
hospital
where
the
Medical
Records
are
also
used
for
educational
purposes.”
(Pourasghar
et
al,
2008)
• “Inadequacies
were
found
in
clinical
documentation,
especially
gross
underutilization
of
discharge
summary
forms.
Some
forms
were
properly
documented,
suggesting
that
hospital
healthcare
providers
possess
the
necessary
skills
for
quality
clinical
documentation
but
lack
the
will.”
(Adeleke
et
al,
2012)
• “…medication
details
were
frequently
omitted
or
inaccurate
…
lack
of
clarity
about
follow-­‐up
plans
regarding
further
investigations
and
visits
to
other
consultants
as
the
areas
requiring
the
most
improvement.”
(Legault
et
al,
2012)

8. About Discharge Summary
• “…accurate
identification
of
clinical
abbreviations
is
a
challenging
task
and
advanced
abbreviation
recognition
modules
are
needed…”
(Wu
et
al,
2012)
• “…audit
and
feedback
sessions
significantly
improved
the
completeness
of
discharge
summaries
dictated
by
geriatric
medicine
fellows
at
one
academic
medical
center.”
(Dinescu
et
al,
2011)
• “An
Electronic
Discharge
Summary
program
can
be
used
by
housestaff
to
more
easily
create
hospital
discharge
summaries…”
(Maslove
et
al,
2009)

9. Unreliable Discharge Summary, then?
• Admission
form
• Integrated
medical
record
• Medical
• Nursing
• Other
health
profession
• Surgery
report
• Supporting
results
• Laboratory
• Radiology
/
Imaging
• Electromedics
• Others
• Transfusion
“flag”
http://a57.foxnews.com/

10. Koleksi
Pribadi

11. Koleksi
Pribadi

12. Koleksi
Pribadi

13. Koleksi
Pribadi

14. Koleksi
Pribadi

15. Penaggung Jawab Laboratorium
dr. Tri Djoko Endro Susilo, Sp PK
LABORATORIUM RUMAH SAKIT PANTI RAPIH
JL. TEUKU CIK DITIRO 30 YOGYAKARTA
TELP. 0274-563333, 562233, 514845
RM : 014323
REGISTER :
NAMA : ARIAN DATUSANANTYO ROBERTUS DR BP
RUPER : LUAR
UMUR : 31 TH 11 BL 8 HR
JENIS KELAMIN : L
PEMERIKSAAN
HASIL
NO. LAB : 1402250237
DOKTER : APS
TANGGAL :25/02/2014 10:37:01
RUJUKAN
SATUAN
METODE
KET
HEMATOLOGI
Hemoglobin
15.5
13.0 - 17.0
g%
Hema-Automatic
5.0
4.0 - 11.0
10^3/ul
Hema-Automatic
Eritrosit
5.28
4.50 - 6.50
10^6/ul
Hema-Automatic
Hematokrit
47.3
40.0 - 54.0
%
Hema-Automatic
Trombosit
202
150 - 450
10^3/uL
Hema-Automatic
Eosinofil
5.9
1.0 - 6.0
%
Hema-Automatic
Basofil
0.7
1.0 - 2.0
%
Hema-Automatic
Neutrofil
54.4
40.0 - 80.0
%
Hema-Automatic
Limfosit
26.5
20.0 - 40.0
%
Hema-Automatic
Monosit
12.6
2.0 - 10.0
%
Hema-Automatic
MCV
89.6
80.0 - 96.0
fl
Hema-Automatic
MCH
29.3
27.0 - 31.0
pg
Hema-Automatic
MCHC
32.8
32.0 - 36.0
g/dl
Hema-Automatic
RDW-CV
13.3
11.6 - 14.8
%
Hema-Automatic
Lekosit
HITUNG JENIS LEKOSIT
L
H
INDEKS ERITROSIT
Catatan :
Koleksi
P
Yogyakarta, 25 FEBRUARI 2014 ribadi

16. Koleksi
Pribadi

17. Koleksi
Pribadi

18. Koleksi
Pribadi

19. Case
Mrs
S.W.,
female,
53
y.o.
was
referred
by
a
medical
oncologist
to
our
internal
medicine
ward.
She
was
diagnosed
with
a
Non-­‐
Hodgkin
Lymphoma
and
an
advanced
grade
of
Haemorrhoid.
She
had
a
surgery
during
her
13-­‐day
hospitalization
and
received
supportive
treatment
for
her
NHL,
tranfusion
of
packed
red
cells,
and
antibiotics
for
amebic
gastroenteritis.
Her
discharge
summary
was
completed
by
the
medical
oncologist
without
stating
anything
about
surgery
and
surgeon
consultation.
The
swap
between
primary
and
secondary
diagnoses
was
performed
by
the
coder
and
she
found
an
interesting
fact.
A
modification
of
DS
is
therefore
necessary.

20. Common Problems
• Unrecognizable
handwriting
• Different:
admision
and
discharge
diagnosis
• Common
diagnosis
confusion:
• Post
laparatomy
• Abbreviation
• Medical
procedure
confusion:
• Incomplete
• Abbreviation
• Unrecorded
consultation
• Primary
and
secondary
diagnoses
vs
attending
phycisians’
role
• Tariff
consideration
(?)
Source:
Interview
with
Coders
http://www.pharmacyerrorinjurylawyer.com/
• Post
partum

21. http://www.commonsenseevaluation.com/

22. Fraud and Abuse. Corruption?
• Fraud:
Intentional
deception
or
misrepresentation
that
the
individual
or
entity
makes
knowing
that
the
misrepresentation
could
result
in
some
unauthorized
benefit
to
the
individual,
or
the
entity
or
to
some
other
party.
(NHCAA,
2012)
• Abuse:
Unintentional
practice
that
directly
or
indirectly
results
in
an
overpayment
to
the
healthcare
provider.
(Rudman
et
al,
2009)
• Corruption
(Riyanto,
2009)
• Desire
to
act,
• Ability
to
act,
• Opportunity
to
do
corruption,
• Suitable
target.
https://www.unodc.org

23. Intervention in Fraud
• “…a
lack
of
evidence
of
effect
of
the
interventions
to
combat
health
care
fraud.”
(Rashidian,
2012)
• “Do
EHRs
and
other
healthcare
IT
lead
to
increased
fraud
compared
to
paper
medical
records?
Again,
we
do
not
know
the
answer
definitively.
It
has
not
been
properly
studied.
Such
studies
are
difficult
to
perform,
and
true
controlled
studies
are
impossible.”
(Simborg,
2011)
• "Yang
kami
tangkap,
ada
lima
titik.
Investasi
dana
badan
itu,
investasi
dana
jaminan
sosial,
potensi
korupsi
saat
pengalihan
aset,
potensi
korupsi
penggunaan
dana
operasional,
potensi
korupsi
saat
pembayaran
di
fasilitas
kesehatan.
Kami
berterima
kasih
kepada
KPK
yang
mengingatkan
kami
karena
mencegah
itu
lebih
baik
daripada
mengobati,”
(Idris,
2014)

24. Conclusion
• Medical
records
are
the
only
source
of
information
available
for
DRG/CBG
coding
è
Quality
variation.
• Indonesian
hospitals
are
interested
only
in
“reimbursement
factor”.
• Completeness
checking
before
DS
goes
to
coder.
• Internal
audit:
medical
record,
DS,
coding.
• DRG/CBGs
improves
coding
practice?
• Willingness
to
prevent
fraud
and
abuse:
upcoding,
unbundling.
http://networkingstar.com

25. Thank You!
@robertus_arian
|
arian9677@gmail.com
The
content
of
this
presentation
is
author’s
responsibility
and
not
necessarily
reflects
organization’s
view
of
this
topic.
The
author
declares
no
competing
interest.
All
references
used
are
stated
below.
All
picture
sources
are
stated
below
each
picture.

26. References (1)
• Pongpirul
K,
Walker
DG,
Rahman
H,
Robinson
C;
DRG
coding
practice:
a
nationwide
hospital
survey
in
Thailand;
BMC
Health
Services
Research
2011,
11:290
• Pongpirul
K,
Walker
DG,
Winch
PJ,
Robinson
C;
A
qualitative
study
of
DRG
coding
practice
in
hospitals
under
the
Thai
Universal
Coverage
Scheme
;
BMC
Health
Services
Research
2011,
11:71
• Pourasghar
F,
Hossein
M,
Kazemi
A,
Ellenius
J,
Fors
U;
What
they
fill
in
today,
may
not
be
useful
tomorrow:
Lessons
learned
from
studying
Medical
Records
at
the
Women
hospital
in
Tabriz,
Iran;
BMC
Public
Health
2008,
8:139
• Adeleke
IT,
Adekanye
AO,
Onawola
KA,
Okuku
AD,
Adefemi
SA,
Erinle
SA,
Shehu
AA,
Yahaya
OE,
Aebisi
AA,
James
JA,
AbdulGhaney
OO,
Ogundiran
LM,
Jibril
AD,
Atakere
ME,
Achinbee
M,
Abodunrin
OA,
Hassan
MW;
Data
quality
assessment
in
healthcare:
a
365-­‐day
chart
review
of
inpatients’
health
records
at
a
Nigerian
tertiary
hospital;
J
Am
Med
Inform
Assoc
2012;19:1039–1042

27. References (2)
• Legault
K,
Ostro
J,
Khalid
Z,
Wasi
P,
You
JJ;
Quality
of
discharge
summaries
prepared
by
first
year
internal
medicine
residents;
BMC
Medical
Education
2012,
12:77
• Wu
Y,
Denny
JC,
Rosenbloom
ST,
Miller
RA,
Giuse
DA,
Xu
H;
A
comparative
study
of
current
clinical
natural
language
processing
systems
on
handling
abbreviations
in
discharge
summaries;
AMIA
Annu
Symp
Proc.
2012:
997-­‐1003
• Dinescu
A,
Fernandez
H,
Ross
JS,
Karani
R;
Audit
and
feedback:
an
intervention
to
improve
discharge
summary
completion;
J
Hosp
Med.
2011
January
;
6(1):
28–32
• Maslove
DM,
Leiter
RE,
Griesman
J,
Arnott
C,
Mourad
O,
Chow
C,
Bell
CM;
Electronic
Versus
Dictated
Hospital
Discharge
Summaries:
a
Randomized
Controlled
Trial;
J
Gen
Intern
Med
24(9):995–1001

28. References (3)
• NHCAA
(US);
A
Private-­‐Public
Partnership
Against
Health
Care
Fraud
[Internet];
US:
National
Health
Cara
Anti-­‐Fraud
Association;
Consumer
Info
&
Action;
Available
at
http://www.nhcaa.org/resources/health-­‐care-­‐anti-­‐fraud-­‐resources/consumer-­‐
info-­‐action.aspx;
Accessed
March
4th,
2013
• Rudman
WJ,
Eberhardt
III
JS,
Pierce
W,
Hart-­‐Hester
S;
Healthcare
Fraud
and
Abuse;
Perspectives
in
Health
Information
Management
6,
Fall
2009
• Pernyataan
Bibit
S.
Riyanto
(2009)
dikutip
oleh
Niken
Ariati
dalam
seminar
Strategi
untuk
mencegah
Fraud
dan
Korupsi
di
Jaminan
Kesehatan
Nasional;
Jakarta;
November
2013;
Available
at
http://kebijakankesehatanindonesia.net/component/content/article/
2232.html
• Rashidian
A,
Joudaki
H,
Vian
T;
Health
Care
Fraud
and
Abuse:
A
Systematic
Review
of
Literature;
PLoS
ONE
7(8):
e41988.

29. References (4)
• Simborg
DW;
There
is
no
neutral
position
on
fraud!;
J
Am
Med
Inform
Assoc
2011;18:675e677.
• Pernyataan
Fahmi
Idris
(2014)
dikutip
oleh
Kompas
Online;
Available
at
http://nasional.kompas.com/read/2014/02/11/1501433/
KPK.Temukan.Lima.Titik.Rawan.Korupsi.Pengelolaan.JKN.oleh.BPJS