Coding Accuracy in the Return of Inpatient BPJS Claims at Ajibarang Regional General Hospital

Nadiyah Nuur Fauziyah; Ilham Rahmansyah; Khusnul Khotimah Arum

doi:10.55227/ijhet.v4i4.460

Authors

Nadiyah Nuur Fauziyah Politeknik Yakpermas Banyumas
Ilham Rahmansyah
Khusnul Khotimah Arum

DOI:

https://doi.org/10.55227/ijhet.v4i4.460

Keywords:

Coding Accuracy, Pending Claims, BP JS

Abstract

The decline in hospital revenue caused by pending claims remains a major challenge for hospitals. Many hospitals have experienced a decrease, particularly in operational income. Pending claims also affect the health services provided to the community and have an impact on the overall quality of public health. This study aims to determine the coding accuracy of inpatient BPJS claim returns at Ajibarang Regional General Hospital. This research employs a descriptive qualitative design. The population consists of inpatient medical records with pending claims from November 2024, with a total sample of 205 medical records, selected using total sampling. Data were collected through a review of original hospital data sources, and the findings were analyzed to determine the frequency distribution of the causes of pending claims. The results of the study on 205 pending claims showed that the inaccuracy in determining the main diagnosis was 3.41%, inaccuracy in determining diagnosis codes was 29.27%, incompleteness of patient medical record documents was 67.32%, and the highest occurrence of pending claim incompleteness was found in the Internal Medicine Polyclinic (42.44%). It is recommended that the hospital improve staff accuracy and competence through training to reduce the occurrence of pending claims.

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References

Afifah, Nurul, Nadi, Danu Tirta, Sari, & Arum Astika. (2024). Ketidaksesuaian Kode Diagnosis ICD-10 Pada Pending Klaim BPJS Rawat Jalan Di RSUD KRT. Setjonegoro Wonosobo. Jurnal Manajemen Informasi Kesehatan Indonesia, 12(2), 2337–2585. Https://Doi.Org/10.33560/Jmiki.V12i2.626

Agnes Jeane. (2022). Tingkat Ketepatan Kode Diagnosis Penyakit Pada Rekam Medis Di Rumah Sakit Elisabeth Medan. SEHATMAS: Jurnal Ilmiah Kesehatan Masyarakat, 1(3), 397–403. Https://Doi.Org/10.55123/Sehatmas.V1i3.681

Amalia, R., Lestari, S., Ferdianto, A., Akbar, P. S., & Fardilan, N. (2023). Determinan Pengembalian Berkas Klaim Berdasarkan Akurasi Kode Diagnosis Pasien Rawat Inap BPJS Kesehatan Di RSI Sultan Agung Semarang). Jurnal Rekam Medis Dan Informasi Kesehatan, 6(2), 98–104. Https://Doi.Org/10.31983/Jrmik.V6i2.10633

Aryani, L. , Wulandari, R., & Prakoso, A. (2025). Analisis Kelengkapan Dokumen Klaim BPJS Kesehatan Di RSUD Kelas B Jawa Tengah. . Jurnal Administrasi Rumah Sakit Dan Kesehatan, 14(2), 88–96.

Fadilah. (2023). Tinjauan Berkas Klaim Tertunda Pasien Rawat Jalan Bpjs Kesehatan Rs Hermina Galaxy. Jurnal Administrasi Bisnis Terapan, 5(2). Https://Doi.Org/10.7454/Jabt.V5i2.1075

Fahreza, S. A., Sukawan, A., Kemenkes, P., & Korespondensi, T. (2023). Tinjauan Trend Penyebab Pending Claim Jaminan Kesehatan Nasional Rawat Inap Di RSUD Ciamis Review Of Trends In Causes Of Pending National Health Insurance Claims For Inpatient Care At Ciamis Regional Hospital. Jurnal Rekam Medis Dan Informasi, Vol. 1 No. 1, 18–25.

Fakhrur, & Elystia. (2022). Faktor Penyebab Ketidaktepatan Kode Diagnosis Pada Dokumen Rekam Medis Rawat Inap Di Rumah Sakit Islam Aisyiyah Malang. Jurnal Rekam Medis Dan Informasi Kesehatan Indonesia (Jurmiki), 1, 2.

Farhansyah, F., Cahyani, H., Amanda, J., Medis, P. R., Kesehatan, I., & Kesehatan, I. (2024). Faktor Penyebab Pending Klaim Berkas Bpjs Kesehatan Pelayanan Rawat Jalan Di Rumah Sakit X. Kesehatan Tambusai, Volume 5, Nomor 3(3), 8713–8722.

Feby, R. , Astuti, H. , & Rahmawati, D. (2024). Evaluasi Ketidaklengkapan Berkas Rekam Medis Terhadap Proses Pengajuan Klaim BPJS Kesehatan. . Jurnal Rekam Medis Dan Informasi Kesehatan, 13(1), 56–64.

Mukaromah S, & Wahab S. (2024). Analisis Penyebab Pending Klaim Bpjs Rawat Jalan Guna Menunjang Kelancaran Pembayaran Pelayanan Kesehatan Di Rsud Kota Bandung. Jurnal Kesehatan Masyarakat, Volume 8, Nomor 2, 2876–2883.

Setyowati K. (2022). Sistem Jaminan Kesehatan Yang Memenuhi Hak-Hak Kepesertaan. Justice Voice, 1(1), 1–9. Https://Doi.Org/10.37893/Jv.V1i1.27

Tofan, M., Hermawati, M., & Yuliani, R. (2022). Sistem Informasi Rekam Medis Pasien Di Bidan Evi Berbasis Java. Jurnal Riset Dan Aplikasi Mahasiswa Informatika (JRAMI), 03.

Tuzzahra, R., Hakim, A. O., Romodon, D., & Gunawan, G. (2024). Penyebab Pengembalian Berkas Klaim BPJS Kesehatan Pasien Rawat Inap Ditinjau Dari Syarat-Syarat Pengajuan Klaim Di RSUD Majenang. J-REMI : Jurnal Rekam Medik Dan Informasi Kesehatan, 6(1), 29–39. Https://Doi.Org/10.25047/J-Remi.V6i1.5469

Wayan, N., Sari, A. A., & Hidayat, B. (2023). Artikel Asli Analisis Faktor Penyebab Klaim Pending Pelayanan BPJS Di Era JKN. Fakultas Kedokteran Universitas Udayana | Medicina, 54(1), 5–9. Https://Doi.Org/10.15562/Medicina.V54i1.1203

Yunita N, Rusdi A, & Afifah L. (2025). Determinan Pending Claim Badan Penyelenggara Jaminan Sosial Kesehatan Di Rumah Sakit. Syntax Admiration, 6(1).

Yusuf, Z., Nurwanah, A., & Sari, R. (2022). Fraud Pada Program Jaminan Kesehatan Nasional Perpekstif: Kompetensi Auditor Internal Dengan Pendekatan Fenomenologi. Owner, 6(4), 3653–3669. Https://Doi.Org/10.33395/Owner.V6i4.1115