ANALISIS VALIDASI RESUME MEDIS DAN KODE DIAGNOSIS KLAIM BPJS RAWAT INAP DI RSUP DR. M. DJAMIL PADANG

Ropendi Pardede, Edison Edison, Lissa Hamama

Abstract


ABSTRAK

Resume medis dan keakuratan kode diagnosa adalah satu kesatuan yang tidak bisa dipisahkan dari klaim BPJS rawat inap. Jumlah pending klaim BPJS rawat inap RSUP Dr. M. Djamil Padang per bulan berkisar 170 berkas. Tujuan penelitian ini adalah menganalisis validasi resume medis dan kode diagnosa klaim BPJS rawat inap. Jenis penelitian yang digunakan adalah penelitian kualitatif dengan metode observasi wawancara. Informan berjumlah 9 orang. Metode pengumpulan data dengan wawancara mendalam (Indepth Interview), observasi lapangan dan telaah dokumen. Analisa data menggunakan teknik triangulasi. Berdasarkan hasil penelitian validasi resume medis dan validasi kode diagnosa dilakukan oleh case manager. Masih ada resume medis yang tidak sesuai dan tidak lengkap terisi. Validasi resume medis sudah dilakukan berdasarkan Peraturan Menteri Kesehatan Nomor 55 Tahun 2013 dan validasi kode diagnosa sudah dilakukan berdasarkan PMK nomor 76 Tahun 2016. Pihak manajemen disarankan agar kembali memperbaharui aturan dalam pengisian resume medis dan disosialisasikan kepada dokter agar resume medis terisi dengan lengkap. Kepada pihak manajemen juga disarankan agar memperbaharui kebijakan mengenai validasi kode diagnosa dan mengadakan jadwal pertemuan rutin untuk membahas permasalahan yang ada di ruang casemix terhadap validasi kode diagnosa.

 

ABSTRACT

Medical resume and accuracy of the diagnostic code are an inseparable part of the BPJS inpatient claim. The number of pending claims of BPJS inpatient Dr. M. Djamil Padang per month around 170 files. The purpose of this study was to analyze the validation of medical resumes and diagnosis codes for inpatient BPJS claims. This type of research is qualitative research with the interview observation method. There were 9 informants. Methods of data collection by in-depth interviews, field observations, and document review. Data analysis uses triangulation techniques. Based on the results of the research, validation of medical resumes and validation of diagnostic codes were carried out by the case manager. There are still medical resumes that are inappropriate and incompletely filled out. The medical resume validation has been carried out based on the Minister of Health Regulation Number 55 of 2013 and diagnostic code validation has been carried out based on PMK number 76 of 2016. The management is advised to renew the rules for filling out the medical resume and socialize it with doctors so that the medical resume is completely filled. The management is also advised to update the policy regarding diagnostic code validation and to schedule regular meetings to discuss problems in the case-mix room regarding diagnostic code validation.


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References


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