Dengan banyaknya permasalahan klaim INA-CBG dikarenakan perbedaan persepsi antara kedua belah pihak, oleh karena itu telah diterbitkan Surat Edaran Menteri Kesehatan RI Nomor HK.03.03/MENKES/63/2016 tentang Penyelesaian Permasalahan Klaim INA-CBG di JKN.....Link terlampir

SE MENKES TENTANG PERMASALAHAN KLAIM INA-CBG 

Tools WHO-DAS

Untuk Kasus-kasus Sub akut dan kronis diantaranya kasus Jiwa, Kusta dan ketergantungan obat dengan lama rawat > 42 Hari, terdapat tools tambahan yang harus digunakan oleh rumah sakit untuk dapat melakukan klaim kasus kasus tersebut diatas. Semua rumah sakit yang memiliki pelayanan tersebut dapat melakukan klaim dengan catatan memenuhi kriteria tersebut, tools yang digunakan saat ini dalam INA-CBG adalah WHO-DAS. Bagi yang memerlukan silahkan download link berikut :
WHO-DAS

SOFTWARE INA-CBG 4.1 (PAKET)

Bagi Rumah Sakit yang memerlukan aplikasi INA-CBG lengkap dengan updatenya silahkan di klik link berikut, khususnya bagi yang baru bekerja sama, untuk database setup rumah sakit, bisa di kordinasikan selanjutnya.

Karena banyak permintaan, dikarenakan banyak yg tidak mempunyai paket software lengkap sampai dengan perpanjanagn grouper 2015.

Semoga bermanfaat.


Aplikasi INA-CBG 4.1

Apa sumbangsih yang bisa diberikan RS untuk updating tarif INA-CBG ?

Sesuai dengan perpres 12 tahun 2013 dinyatakan bahwa sistem pembayaran INA-CBG digunakan sebagai model pembayaran di fasilitas kesehatan tingkat lanjutan dalam program Jaminan Kesehatan Nasional. Tarif INA-CBG setidak tidaknya akan ditinjau sekurang kurangnya setiap 2 tahun sekali. dalam rangka proses penyempurnaan (updating) tarif INA-CBG diperlukan peran serta rumah sakit sebagai suporting utama dalam pengumpulan data.  Sebelum masuk lebih jauh dalam proses updating tarif, perli dipahami bahwa yang dimaksud dengan updating tarif adalah dilakukan penyesuaian tarif yang disesuaikan dengan kondisi di rumah sakit, jadi jangan di pahami bahwa akan terjadi kenaikan disemua group tarif yang telah ada, akan selalu ada kemungkinan beberapa group tarif yang justru mengalami penurunan tarif. Kembali kepada peran rumah sakit sebagai kontributor utama dalam updating tarif INA-CBG, dimana diperlukan komitmen yang kuat dari rumah sakit untuk proses updating tersebut. Data yang diperlukan dari rumah sakit dalam updating tarif adalah berupa data kosting (keuangan) dan data koding yang berupa data individual pasien. Untuk pengumpulan data kosting, rumah sakit akan diberikan suatu template yang harus diisi sesuai dengan kondisi keuangan rumah sakit, yang di khawatirkan disini adalah banyak rumah sakit yang kurang mampu mengisi dengan baik data keuangan yang diminta, hal ini bisa disebabkan karena sistem akuntansi keuangan rumah sakit yang berbeda dengan template yang diminta atau rumah sakit sendiri yang kurang terbuka mengenai data keuangan, padahal data keuangan tersebut nanti akan sangat berpengaruh terhadap output tarif yang akan dihasilkan. Mengenai Data Kosting ini merupakan data yang sangat sulit mendapat feedback dari rumah sakit, sebagai ilustrasi pada tarif yanag berlaku 2014 ini hanya dapa dikumpulkan dan dapat digunakan datanya sebanyak kurang lebih 134 rumah sakit dari sekitar 2000an rumah sakit yang ada di indonesia saat ini. Mengenai data koding didapatkan dari data individual pasien rumah sakit, kualitas data koding ini juga ditentukan oleh kualitas kelengkapan dokumen resume medis yang menjadi tanggung jawab dokter yang memberi pelayanan, di era saat ini dokter harus mulai merubah pola kebiasaan selama ini yang kurang memperhatikan kelengkapan resume medis pasien, padahal sebenarnya ada atau tidak nya sistem ini, kelengkapa rekam medis merupakan kewajiban dari dokter untuk melengkapi untuk kepentingan pasien dan juga rumah sakit, dan juga kualitas data koding juga ditentukan oleh patuh atau tidaknya pemberi layanan di rumah sakit terhadap aturan pengkodingan yang dalam sistem INA-CBG menggunakan ICD 10 untuk diagnosis dan ICD 9 CM untuk prosedure, karena akibat dari ketidak patuhan terhadap standar pengkodingan dengan sendirinya akan merusak kualitas data koding yang berujung kepada besaran tarif yang nanti yang akan keluar, hal ini disebabkan data koding berperan besa terhadap distribusi pembobotan terhadap kasus- kasus yang terjadi dilapangan yang sebenarnya terjadi. Oleh karena hal tersebut diatas, dimohon kepada rumah sakit supaya dapat memberi sumbangsih lebih besar dalam proses updating tarif INA-CBG, karena semua berawal dari data rumah sakit dan hasil akhirnya juga untuk rumah sakit. Ayo....siapa yang siap dan ingin berkontribusi dalam proses ini??????????????

 

Jenis-Jenis Fraud dalam sistem kesehatan di Amerika, bagaimana di indonesia ?

Below we highlight 15 types of medical billing fraud and abuse affecting the US healthcare system.

1. Upcoding: Typically submitting a claim for a service more severe than the actual service provided. For example, submitting a claim for a broken ankle, when the patient was only treated for a sprained ankle.
2. Cloning: Using an EHR system to automatically generate a more detailed patient observation profile by copying from another patient’s file with similar symptoms to appear as if a more thorough examination was done.
3. Phantom Billing: Billing for services never performed. This also affects healthcare costs in the millions of dollars invested in tracking and prevention.
4. Inflated Hospital Bills:  Gross overcharges for procedures and/or on equipment used on medical bills. For example, $1,500 surgical screws or $500 Tylenol pills.
5. Service Unbundling or Fragmentation:  Billing for multiple procedures separately, that should have been billed together in a bundle in order to forgo the bundled rate and increase profit.
6. Self-Referrals: When a provider refers themselves or a partner provider to perform a service, usually for a financial incentive.
7. Repeat Billing:  Billing twice for the same procedure, supplies or medications.
8. Length of Stay:  Charges for days not in the provider facility.  Most hospitals will charge for the day you arrived, but not for the day you left.
9. Correct charge for type of room:  For example, if you were in a shared room, make sure you’re not being charged for a private one.
10. Time in OR:  Some hospitals charge based on an “average” time needed to perform an operation instead of the actual operation time.
11. Keystroke Mistake:  Entering incorrect codes, resulting in significant overcharges or in some cases an undercharge.
12. Cancelled Service:  Occasionally a medication, procedure or service that was prearranged and then canceled later but is still charged.
13. No Medical Value:  Claims submitted for payment for poor service that resulted in a decline in patient’s health.
14. Standard of Care:  Billing for services in which the provider failed to meet quality standards of care and provide preventative actions to safeguard patient’s health.
15. Unnecessary Treatment:  When a provider performs unnecessary tests in order to bill for them.

Penyebab Umum koding Error dan Cara Pencegahannya

Common Coding Errors and How to Prevent Them

For those of us who work with coders as managers, auditors, co-workers, or consultants, we know how conscientious, dedicated, hard-working, and detail-oriented this group of professionals can be. When errors in their work are discovered, most are extremely upset with themselves and they work even harder to improve their coding skills. Although as humans we inevitably make occasional mistakes, an analysis of common errors found in auditing inpatient records suggests there are several reasons why coding errors are made. This article addresses some of the common coding errors and suggests some ways to prevent them. Knowing where the “traps” are should help to avoid them.

1. Carelessness:  Choosing productivity as a priority over quality can cause a coder to rush through a medical record without thoroughly reading all available documentation. Additionally, the distractions and disruptions that occur in the environment may result in errors.
2. Encoder pathways:  Coders who use clinical encoders during the coding process follow coding pathways to determine code and DRG assignments. As useful as these encoders are, they cannot prevent coding errors; following an incorrect coding pathway may result in an incorrect code assignment without the coder even realizing that an error has occurred.
3. Memorizing diagnosis and procedure codes:  Experienced coders cannot help but memorize many code assignments after using them repeatedly. Sometimes, however, our memories fail and the direct entry of memorized codes may lead to error.
4. Incomplete or inadequate documentation:  When documentation is incomplete or conflicting, it is difficult for the coder to code completely and accurately. Since coding is frequently completed before discharge summaries or other dictated reports are available, final conclusions/diagnoses may differ from those determined by the coder in reviewing History & Physical Reports and progress notes alone.  
5. Incorrect principal diagnosis selection:  Errors in selecting the principal diagnosis may be the result of a lack of knowledge of basic coding principles and terminology. The quality of the coder’s initial training program and/or “on-the-job experience” is fundamental to coder expertise, as is the coder’s ability to stay abreast of current coding guidelines. Misunderstanding or misinterpreting a coding guideline may also occur by failing to read encoder messages, inclusion and exclusion terms, and coding references during the coding process. Common examples of incorrect principal diagnosis selection include:
   • Coding a condition when a complication code should have been selected instead.
   • Coding a symptom or sign rather than the definitive diagnosis.
   • Assuming a diagnosis without definitive documentation of a condition.
   • Coding from a discharge summary alone.
   • Incorrectly applying the coding guidelines for principal diagnosis, especially in a situation where the coder selects the diagnoses when two or more diagnoses equally meet the definition of principal diagnosis.
6. Incorrect or missing secondary diagnoses:  Secondary diagnoses are frequently coded when they do not meet the criteria for reporting secondary diagnoses. Some of the “traps” in coding secondary diagnoses are found in physician documentation. Examples include:  (1) Using the term “history of” for conditions that are currently under treatment, as well as for those that have been resolved prior to admission; (2) Misusing the term “coagulopathy.” It is often documented when a patient on anticoagulant therapy has an expected prolonged prothrombin time, rather than a true coagulopathy.   Secondary diagnoses may be missed by coders who code from a discharge summary alone without reviewing all documentation.
7. DRG assignment errors:  In addition to the challenges of selecting the principal diagnosis and coding appropriate secondary diagnoses and procedures, failure to review the code list and DRG assignment may result in a DRG that does not “fit” with the patient’s stay.  

RECOMMENDATIONS:

1. Focus on quality, not just productivity. The quality of coded data is more critical than ever before, given the use of these data and the extensive scrutiny of third party payers. This fact justifies taking the time to focus on coding accuracy and reading medical record documentation thoroughly. Try to eliminate as much of the daily distractions and disruptions in the workplace as possible. 
2. To avoid encoder pathway errors, read the entire list of coding choices before continuing down the pathway, and then review the code assignment(s) to determine if the code selected seems to “fit” the condition or procedure. Use the ICD-9-CM coding manual as a reference tool, even when using clinical encoders.
3. Query conflicting and incomplete documentation. When a record has been coded without a final discharge summary, a process should be developed for reviewing them when it is complete.  Remember that Recovery Audit Contractors and other external auditors have access to the entire medical record when a record request is received.  If such final review of a discharge summary results in a different DRG assignment, the claim should be resubmitted.
4. Take time to read and analyze the entire medical record before finalizing code assignments; apply critical thinking skills when reviewing documentation and code assignments. 
5. Review the official coding guidelines for principal diagnosis. When multiple conditions may be present or suspected on admission, it is especially challenging to determine if the guideline for two or more diagnoses meeting the definition of principal diagnosis may be applied.
6. Review current coding guidelines frequently, especially those topics that may be troublesome, such as respiratory failure, sepsis, complications of treatment, coagulopathy, and signs/symptoms.  
7. Review all questionable code assignments with your supervisor or another coder; sometimes a discussion with another coder is enough to clarify your questions.
8. Query as necessary; be clear and concise and avoid “leading” physicians to a diagnosis.
9. Exercise care when coding secondary diagnoses from the History & Physical. Remember that the definition of “other diagnoses” for reporting purposes is conditions that affect patient care in terms of requiring clinical evaluation, therapeutic treatment, diagnostic procedures, extended length of hospital stay, or increased nursing care and/or monitoring. A condition that meets only one element of this definition may be coded; conditions that do not meet this definition should not be coded.
10. Review the completed code list and DRG assignment; this requires only a minimal amount of time and may prevent a DRG error.

The importance of accuracy in coding cannot be underestimated. As coders in the current data-driven healthcare environment, expectations are high and the challenges are many. Now is the time to assess your coding skills and use all resources available to improve them to ensure coded data of the highest quality.

Software INA-CBG 4.1 expired

 Software INA-CBG expired

Pertanggal 31 Desember 2014 yang lalu software INA-CBG 4.1 habis massa berlaku untuk grouper nya, dan oleh National Casemix Center (NCC) telah dilakukan re-aktivasi kembali, untuk seluruh rumah sakit di indonesia, silahkan download di tautan berikut ini :

Update Re-aktivasi Software INA-CBG 4.1

Perpanjangan Grouper Juni 2015