Accuracy of Coding Related to Mammary Carcinoma in Surgery Cases According to ICD-9-Cm Procedures in the Smoothness of BPJS Health Claims at Toto District Hospital in Bonebolang Regency, Gorontalo Province
DOI:
https://doi.org/10.56338/ijhess.v8i3.10817Keywords:
Coding Accuracy, Breast Cancer, Carcinoma Mammae, ICD-9-CM, BPJS Kesehatan, Medical Records, INA-CBGsAbstract
Accurate coding of surgical procedures is essential for the quality of medical records, health information reporting, and the verification of BPJS Kesehatan claims. This study analyzed the accuracy of coding for carcinoma mammae in surgical cases according to ICD-9-CM procedures and examined its relationship with the smooth processing of BPJS Kesehatan claims at Toto Kabila Regional General Hospital, Bone Bolango Regency, Gorontalo Province. A descriptive qualitative design with an observational approach was used. Five informants were selected purposively, consisting of a coding officer, the head of the medical records unit, case-mix staff, a case-mix coordinator, and medical records staff. Data were collected through in-depth interviews, observation, and document review and analyzed through data reduction, data presentation, and conclusion drawing. The findings indicate that diagnosis coding for carcinoma mammae was relatively consistent because tumor topography was generally documented clearly. In contrast, procedure coding using ICD-9-CM remained vulnerable to errors because surgical reports did not always specify important procedural details, including unilateral or bilateral status, the extent of excision, and axillary dissection. In the 14 carcinoma mammae cases reviewed, 11 claims were successfully processed, whereas three could not be claimed because of coding inaccuracies and incomplete surgical documentation. Internal clarification between coders, medical records staff, operating units, and physicians helped correct incomplete records, but also increased the workload and could delay claims. The study concludes that completeness of surgical documentation, coder competence, interprofessional communication, and routine evaluation are central to improving coding accuracy and supporting timely BPJS claim processing.
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