The Influence of Coding Quality and Completeness of Medical Records on Pending Claims for Inpatient Services at West Sidoarjo Regional Hospital
Pengaruh Kualitas Pengodean dan Kelengkapan Rekam Medis terhadap Pending Klaim Rawat Inap di RSUD Sidoarjo Barat
DOI:
https://doi.org/10.21070/ups.11873Keywords:
Pending Claim, Medical RecordAbstract
Pending claims frequently delay hospital reimbursements in the BPJS Health system. This descriptive quantitative study analyzed claim document completeness, diagnosis coding accuracy, and contributing factors to pending inpatient claims at RSUD Sidoarjo Barat. Using a prospective approach, 98 inpatient claim files were selected via purposive sampling and analyzed through descriptive statistics and Odds Ratio (OR) analysis.
The results revealed that administrative document completeness reached 100%. However, diagnosis coding accuracy stood at 85%, leaving 15% inaccurate. Consequently, claim verification showed 86% eligible claims and 14% pending claims. OR analysis demonstrated a significant association between diagnosis coding accuracy and claim status (OR = 39.2; 95% CI = 16.82–92.99; p < 0.001).
These findings demonstrate that complete administrative documents alone cannot prevent pending claims if coding inaccuracies persist. To reduce pending BPJS claims, hospitals must improve diagnosis coding accuracy and strengthen internal claim verification processes.
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