Coding Audit Application to Support Diagnostic Code Quality

Abstract

Coding audits in healthcare are crucial for maintaining the quality of diagnostic and treatment coding. Current challenges related to coding audits include the lack of electronic instruments to assist in the implementation of clinical coding audits. Most audits are performed manually, which is time-consuming and prone to high human error. Therefore, an application that generates periodic reports is needed to maintain coding quality and generate data quickly and easily, resulting in accurate and timely information. This research method is qualitative. The design method used is the waterfall approach: Requirements Analysis, System Design, Implementation, Testing, and Maintenance. The population in this study was a secondary care hospital in Boyolali Regency. The sampling technique consisted of six auditors. Data collection methods included interviews and observations. The system was tested using the PIESCES technique. The audit coding application results can assist coding audit staff in generating audit results, including code accuracy, timeliness of filling, and compliance. The information generated is faster, more accurate, and can generate periodic reports according to the hospital's needs. The assessment results concluded that the application is suitable for use in healthcare services. The Performance score was 100% strongly agree, with scores for Information 66.6%, Economics 83%, Control 66.6%, Efficiency 83%, and Service 66.7%. The Audit Coding application can assist coding audit staff in conducting analyses to obtain precise and accurate information. Reports can be printed at any desired period, ensuring the quality of disease and procedure coding. Reports are generated in the form of percentages of code accuracy, timeliness of filling, and compliance.