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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.
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Medical Record for DRG/CBG Coding Purpose dr. Robertus Arian D. Head of Emergency Dept. Panti Rapih Hospital
http://www.jacksongeneral.com
Topics
• Literature Review
• Medical Record Files
• Problems
• Fraud
• Conclusion
http://i.livescience.com
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
Learning from Thailand (2) –Hosp. Intention
• FACTOR 1 – Data Quality • Audit • Improvement
• 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
http://images.amari.com
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
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
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)
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)
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/
Koleksi Pribadi
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LABORATORIUM RUMAH SAKIT PANTI RAPIH
NAMA :RUPER :
REGISTER :
ARIAN DATUSANANTYO ROBERTUS DR BPLUAR
RM : 014323
UMUR :31 TH 11 BL 8 HR JENIS KELAMIN LDOKTER : APS
TANGGAL :25/02/2014 10:37:01
PEMERIKSAAN HASIL RUJUKAN SATUAN KET
:
METODE
JL. TEUKU CIK DITIRO 30 YOGYAKARTATELP. 0274-563333, 562233, 514845
Penaggung Jawab Laboratoriumdr. Tri Djoko Endro Susilo, Sp PK
NO. LAB : 1402250237
HEMATOLOGI Hemoglobin 15.5 g%13.0 - 17.0 Hema-Automatic Lekosit 5.0 10^3/ul4.0 - 11.0 Hema-Automatic Eritrosit 5.28 10^6/ul4.50 - 6.50 Hema-Automatic Hematokrit 47.3 %40.0 - 54.0 Hema-Automatic Trombosit 202 10^3/uL150 - 450 Hema-Automatic HITUNG JENIS LEKOSIT Eosinofil 5.9 %1.0 - 6.0 Hema-Automatic Basofil 0.7 %1.0 - 2.0 LHema-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 HHema-Automatic INDEKS ERITROSIT MCV 89.6 fl80.0 - 96.0 Hema-Automatic MCH 29.3 pg27.0 - 31.0 Hema-Automatic MCHC 32.8 g/dl32.0 - 36.0 Hema-Automatic RDW-CV 13.3 %11.6 - 14.8 Hema-Automatic
Kalau ada keraguan hasil,Harap segera menghubungi instalasi laboratorium
Catatan : Yogyakarta, 25 FEBRUARI 2014
Disetujui
WAWAN
11:46:27
Cetak : 05/03/2014 12:24:25
dicetak oleh 10035
hal 1 dari 1
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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.
Common Problems • Unrecognizable handwriting • Different: admision and discharge diagnosis • Common diagnosis confusion: • Post laparatomy • Post partum • Abbreviation
• Medical procedure confusion: • Incomplete • Abbreviation
• Unrecorded consultation • Primary and secondary diagnoses vs attending phycisians’ role • Tariff consideration (?)
http
://www.pha
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yerror
injurylawye
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/
Source: Interview with Coders
http://www.commonsenseevaluation.com/
Fraud and Abuse. Corruption?
https://www.unodc.org
• 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.
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)
Conclusion
http://networkingstar.com
• 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.
Thank You! 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.
@robertus_arian | [email protected]
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
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
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.
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