Review Of The Accuracy Of Carcinoma Mammae Diagnosis Codes In Inpatients Based On ICD-10 At Bhayangkara M. Hasan Hospital Palembang For The First Quarter Of 2025
Abstract
The accuracy of the diagnosis code plays a significant role in supporting the smooth reporting of hospitals, claims, and health statistics. This study aims to determine the percentage of accuracy of the diagnosis code for Carcinoma Mammae based on ICD-10 and to identify obstacles in coding the diagnosis of Carcinoma Mammae in hospitalized patients at the Bhayangkara M. Hasan Hospital, Palembang, in the first quarter of 2025. This study uses a descriptive method with a quantitative approach. The study population was all medical record files of inpatients with a diagnosis of Carcinoma Mammae, and the sample used was 15 files with a total sampling technique. Data collection was carried out through observation of medical record files and interviews with coding officers. The results showed that of the 15 samples of medical record files, 13 files (86,7%) had accurate diagnosis codes according to ICD-10, while 2 files (13,3%) were inaccurate. The obstacles found included the doctor's writing that was difficult to read, incomplete medical resumes, and the unavailability of supporting documents such as supporting examination results. The conclusion of this study shows that most of the carcinoma mammae diagnosis coding process has been running well and according to procedure, although improvements are still needed. Therefore, it is necessary to improve medical documentation and cooperation between medical personnel and coders to reduce errors in diagnosis coding
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