Relationship Between Specificity and Precision in Writing the Main Diagnosis and Accuracy of Main Diagnosis Codes with Financing Claims in Cases of DM in Dr Radjiman Wediodiningrat Hospital, Lawang

  • Endang Sri Dewi Hastuti Suryandari Malang State Health Polytechnic, Indonesia
Keywords: Specificity and precision in writing the main diagnosis, accuracy of main diagnosis codes, claims financing


Specificity and precision in writing the main diagnosis will give the accuracy of diagnosis code, and proper code will give an impact on the appropriate of the cost using INA-CBGs. Research objectives was to analyze the specificity and precision in writing the main diagnosis and the accuracy of main diagnosis code based on ICD-10, also the claims of financing in the case of Diabetes Mellitus (DM) in RSJ Dr. Radjiman Wediodiningrat Lawang, as well as analyzed their relationship. This type of research was a cross sectional correlasional. Independent variables were the specificity and precision in writing the main diagnosis and the accuracy of main diagnosis code, and the dependent variable was the claim of financing. The number of samples analyzed were 50 inpatient medical record document (MRD) of DM cases which hospitalization from January to September 2017, selected by simple random sampling. The results showed the unspecific and unprecise in writing the main diagnosis of DM disease had a risk 1.6 times greater impacting the inaccuracy the main diagnosis code of DM disease (95% CI: 1.05 - 2.30) and 1.8 times greater resulting in the claims for financing treatment not accordance (95% CI: 1.03 - 3.12). An internal verification team is needed for submission of financing claims, consisting of elements from the medical committee, medical recorders and other related elements, as well as conducting periodic monitoring and evaluation of how to write the main diagnoses and their coding.


Abdelhak, M., & Hanken, M. A. (2012). Health Information Management of a Strategic Resource. 5th Edition. Elsevier Saunders. 421-691
Danzi, J. T., Masencup, B., Brucker, M. A., & Dixon-Lee, C. (2000). Case study: clinical documentation improvement program supports coding accuracy. Top Health Inf Manage, 21(2), 24-29. Retrieved from
Departemen Kesehatan Republik Indonesia. (2008). Pedoman Pengelolaan Rekam Medis Rumah Sakit di Indonesia, Revisi 2, Jakarta.
Farhan, J., Al-Jummaa, S., Alrajhi, A. A., Al-Rayes, H., & Al-Nasser, A. (2005). Documentation and coding of medical records in a tertiary care center: A pilot study. Annals of Saudi Medicine, 25(1), 46-49.
Fernandez, V. (2017). “Ins and Outs of HCCs.” Journal of AHIMA, 88(6), 54-56
Hamid. (2013). Hubungan Ketepatan Penulisan Diagnosis Dengan Keakuratan Kode Diagnosis Kasus Obstetri Gynecology Pasien Rawat Inap di RSUD Dr Saiful Anwar Malang. Retrieved from , tanggal 1 Nopember 2017
Hatta, G. R. (2013). Pedoman Manajemen Informasi Kesehatan di Sarana Pelayanan Kesehatan, Edisi Revisi 2, Jakarta, Penerbit Universitas Indonesia.
Keputusan Menteri Kesehatan Republik Indonesia Nomor 844/ MENKES / SK / X / 2006 tentang Penetapan Standar Kode Data Bidang Kesehatan.
Kveton, N. (2018). Improving Accuracy of Clinical Documentation Positively Impacts Risk Adjustment Factor and HCC Coding. Posted in Accountable Care, Data Quality, Management & Governance and Payers & Providers. HealthCatalyst.
Linder, H. (2012). ASC Coding, Billing, and Collections. 5 Common Fraudulent Coding, Billing Schemes.
O'Malley, K. J., Cook, K. F., Price, M. D., Wildes, K. R., Hurdle, J. F., & Ashton, C. M. (2005). Measuring Diagnoses: ICD Code Accuracy. Jurnal Health Service Research, 40(5 Pt 2), 1620-1639.
Peraturan Menteri Kesehatan No.36 Tahun 2015 tentang Fraud.
Permenkes Nomor 76 tahun 2016 tentang Pedoman INA-CBGs Dalam Pelaksanaan Jamkesnas.
Prophet, S. (1997). Fraud and Abuse Implications for the HIM Professional. Journal of AHIMA, 68(4), 52-56.
Shofari. (2002). Pengelolaan Sistem Rekam Medis Kesehatan. Semarang.
Word Health Organization. (2011). ICD -10 (International Statistical Classification of Diseases and Related Health Problems), 1, 2, 3. (2010 Edition). ISBN 978 92 4 154 8342.
Word Health Organization. (2014). ICD 10 - 2010, Update Review 2013. Module Development.