Design of a Computer-Assisted Coding System with Rule-Based Validation Based on ICD-10 at STIKES Wira Medika Bali

Ni Luh Dwie Ratna Dewati Saraswati; Ika Setya Purwanti; Made Wahyu Aditya

doi:10.55227/ijhet.v5i3.1172

Authors

Ni Luh Dwie Ratna Dewati Saraswati Sekolah Tinggi Ilmu Kesehatan Wira Medika Bali
Ika Setya Purwanti
Made Wahyu Aditya

DOI:

https://doi.org/10.55227/ijhet.v5i3.1172

Keywords:

Computer-Assisted Coding; Rule-Based Validation; ICD-10; Diagnosis Coding; Health Information Management

Abstract

The coding of diagnoses and procedures is a critical activity in health information management, yet it remains prone to errors that affect claim accuracy and the financial sustainability of healthcare facilities. Inaccurate coding can lead to upcoding or downcoding, both of which carry administrative and financial risks. This study aims to design a Computer-Assisted Coding (CAC) system with rule-based validation based on the International Classification of Diseases, 10th Revision (ICD-10), tailored to the learning environment at STIKES Wira Medika Bali. A qualitative descriptive approach using a system design research methodology was employed. Data were collected through literature review and observation of the diagnosis-coding learning process at the Medical Records Management Laboratory. The analysis identified functional requirements for accepting diagnosis input, facilitating ICD-10 code search, and providing automatic validation notifications based on predefined rule-based criteria. The system design produced a flowchart, Context Diagram, Data Flow Diagram (DFD), Entity Relationship Diagram (ERD), and a user interface prototype comprising a login page, a main page with diagnosis input and code-search features, and validation result notifications. The resulting design provides a structured foundation for developing a fully functional CAC application that supports more systematic, accurate, and efficient diagnosis coding education.

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