Analisa Data
Klaim JKN
Gandi Agusniadi
Concurrent UR Retrospective UR
: Evaluasi yang dilakukan : Evaluasi yang dilakukan
selama layanan kesehatan setelah layanan kesehatan
berlangsung dilakukan
- Memantau Kepatuhan - Analisa data klaim dan atau
pelaksanaan Clinical Pathway analisa data biaya RS
--Pengisian Resume Medis
#OverView-2
#Data.txtKlaimIna-CBG?
: Output Aplikasi e-Klaim periode tertentu
dengan format .txt yang digunakan sebagai
media untuk menghitung jumlah layanan
yang dilakukan Faskes penyelenggara JKN
dan akan ditagihkan ke pihak BPJS
Kesehatan dan pihak lain yang
menggunakan pola pembiayaan Casemix
Ina-CBG
#daridanbagaimana
MendapatkanData.txtKlaimIna-CBG?
: 1. Data Center Kementerian Kesehatan RI :
https://inacbg.kemkes.go.id/dc
Standar Akreditas :
# SNARS
# JCI
Klaim
# Patient Safety
MONITORING RESUME MEDIS DI SIM RS
0)
MONITORING RESUME MEDIS
Laporan Pasien Pulang 2020-10-01 - 2020-10-31 DI EHR
(3 NOV 2020)
No MRN Nama Pasien Tgl Masuk Tgl Pulang Unit Perawatan Jaminan SEP Status Inap Status Resume Status INACBG
1 443-04-00 SITI ZAENAB BY NY 24 Desember 2019 19:13 21 Oktober 2020 18:30 UPK/Div. Perinatologi - JAMINAN KESEHATAN NASIONAL 0901R0011219V046284 Pulang Open
SEP Status Inap Status Resume Status INACBG
NAL2 345-25-46 HARTONO D. PUSPONEGORO
0901R0011219V046284 6 Februari 2020 20:29 10 Oktober 2020 17:19
Pulang IGD - Intensive Care Unit (ICU) - ICU Open
IGD JAMINAN KESEHATAN NASIONAL 0901R0010220V016729 Meninggal Final Sukses Grouping
Pelayanan Penyiapan berkas Koding Penyakit & Data entry & Grouping
Prosedur oleh INA-CBG online EHR oleh
RI dan RJ pendukung klaim oleh
Koder Unit RM Petugas RM
Penata rekening
Pengajuan Klaim
Monitoring pasien
BPJS
JKN yg sdh atau
Verifikator Internal belum di klaim
Indikator
#ReviewPreClaim&
PenanganPotensiFraud
1. LOS
2. Severity Level Rates
3. Rates of Referral to Other Facilities
4. Fragmentation outpatient visite
5. Readmision inpatient visite
6. Mortality case rates
7. Rates of Use of Special CMG
8. Up-coding
TEXT FILE >>> EXCEL>>>DATA CENTER KEMENKES
Pembahasan Potensi
Fraud
TTD Pernyataan
Tim Fraud
12
Kriteria Potensi Fraud Koding >> Cek TXT Bulanan
dan potensi pending atau gagal klaim
• Hypertensi (I10-I15) dng I20-I25 >>> I10-I15 harus sekunder
• Kanker dng J90 (Pleural Effusi) >>> Cek hasil PA
• CHF dng Hypertensi (I50+I10 I11)
• PPOK & Pneumonia : J44.0 + J18 >> J44.0
• N20-N23 dan N13.2 >>> N13.2
• N13.2 + N39.0 kodenya hanya N13.6
• N30-39 dng Urolithiasis (N20-N23) >>> N20-N23
• A41.9 dng N39.0 >>> N39.0 (Sepsis Urinary)
• Bronchitis dng umur = J40 = 3 (>15Th) >>> J20 = 10 (umur < 15)
• ALO dng HF = J81 dan I50 >>> I50.1
• A09 + A01 = A01
• S06.2 & G93.5 ->> G93.5 sudah include S06.2 jika trauma
• I60-I69 + I10&I15 I10-I15 harus sekunder
• O41 (Oligohidroamnion) + O42 (KPD) kodenya hanya O42
• R57.1 : Shock Hypovolaemic Obtetric : O75.1; Hamil aborsi atau
ectopic : O00-O07, 008.3 =
• TBC & Pnemonia : J18 & A15-A16 = A15-A16
• HIV : B20-B24
Kriteria Analisa Data Klaim :
1.Penulisan kode diagnosis yang berlebihan/upcoding
2.Admisi yang berulang/readmisi
3.Pemecahan episode pelayanan/servise unbundling or
fragmentation
4.Menambah panjang waktu penggunaan ventilator
5.Severity level III >>> LOS 1-4 Hari
6.Indikasi rawat inap (indikasi LOS <2 hari) keculai pelayanan
kemoterapi dan Radioterapi
1
4
Contoh
I
75%
ALOS=4,5
Contoh Casemix Main Group (CMG)
CMG Jumlah
NO. Case-Mix Main Groups (CMG) ALOS Rank
Codes Kasus
1 A Infectious & parasitic diseases Groups 994 7.3 3
2 B Hepatobiliary & pancreatic system Groups 160 5.5 16
3 C Myeloproliferative system & neoplasms Groups 322 3.4 10
4 D Haemopoeitic & immune system Groups 96 4.5 19
5 E Endocrine system, nutrition & metabolism Groups 261 5.1 11
6 F Mental Health and Behavioral Groups 4 3.8 21
7 G Central nervous system Groups 954 5.3 4
8 H Eye and Adnexa Groups 99 3.1 18
9 I Cardiovascular system Groups 704 4.9 6
10 J Respiratory system Groups 760 5.2 5
11 K Digestive system Groups 1528 4.4 1
12 L Skin, subcutaneous tissue & breast Groups 455 4.0 8
13 M Musculoskeletal system & connective tissue Groups 627 3.9 7
14 N Nephro-urinary System Groups 1095 4.2 2
15 O Deleiveries Groups 250 3.4 12
16 P Newborns & Neonates Groups 144 4.7 17
17 S Injuries, poisonings & toxic effects of drugs Groups 53 3.5 20
18 U Ear, nose, mouth & throat Groups 385 4.0 9
19 V Male reproductive System Groups 161 4.2 15
20 W Female reproductive system Groups 207 4.3 14
Factors influencing health status & other contacts with
21 Z 228 4.7 13
health services Groups
Casemix Main Group (CMG)
Contoh
2500
2015
2000
1500
1325
1177
1078 1094
1000 927
820
595
500 450 427
340 358
253 269
171 142 170
104 64
7
0
A B C D E F G H I J K L M N O P S U V W
Contoh DISCHARGE STATUS
Dirujuk APS
0% 1% Meninggal
6%
Lain2
0%
DISCHARGE_
Percent
STATUS Freq.
Sembuh
Sembuh 8,794 92.70
93% Dirujuk 57 0.60
APS 86 0.91
Meninggal 536 5.65
Lain2 14 0.15
Contoh Kelas Rawat
Kls.3
ALOS : 5,1
53%
Kls.2
ALOS : 4,3
28%
Contoh
20 Besar Diagnosis Utama & ALOS
No ICD10 Deskripsi ICD Jumlah ALOS
1 A90 Dengue fever [classical dengue] 497 5,3
2 K52.9 Noninfective gastroenteritis and colitis, unspecified 478 4,1
3 A09.9 Gastroenteritis and colitis of unspecified origin 452 4,0
4 Z51.1 Chemotherapy session for neoplasm 389 2,7
5 I12.0 Hypertensive renal disease with renal failure 374 4,4
6 B34.9 Viral infection, unspecified 321 4,3
7 J40 Bronchitis, not specified as acute or chronic 307 5,2
8 I63.3 Cerebral infarction due to thrombosis of cerebral arteries 299 5,3
9 K30 Dyspepsia 269 4,0
10 N18.5 Chronic kidney disease, stage 5 255 4,1
11 M54.96 Dorsalgia Lumbar region 181 2,4
12 H81.1 Benign paroxysmal vertigo 180 3,4
13 Z47.0 Follow-up care involving removal of fracture plate and other internal fixation device 158 2,8
14 I10 Essential (primary) hypertension 157 4,0
15 K35.8 Acute appendicitis, other and unspecified 138 4,5
16 I64 Stroke, not specified as haemorrhage or infarction 136 4,6
17 I11.0 Hypertensive heart disease with (congestive) heart failure 126 5,0
18 A01.4 Paratyphoid fever, unspecified 124 5,0
19 H26.9 Cataract, unspecified 124 3,0
20 J18.0 Bronchopneumonia, unspecified 111 5,4
20 Besar INACBG Rawat Inap
Contoh
RAWAT INAP
Kode INA-
No Deskripsi Kode INA-CBG Jumlah
CBG Tarif INA-CBG Tarif Riil RS Selisih %
Kasus ALoS
1 2 3 4 5.0 6 7 8 9
1 A-4-13-I INFEKSI VIRAL & NON-BAKTERIAL LAIN (RINGAN) 637 7.8 1,428,013,400 22,238,668,851 (20,810,655,451) 6.4
2 K-4-17-I NYERI ABDOMEN & GASTROENTERITIS LAIN-LAIN (RINGAN) 601 3.9 1,153,195,100 1,427,610,947 (274,415,847) 80.8
3 N-4-10-II TUMOR GINJAL & SALURAN URIN & GAGAL GINJAL (SEDANG) 340 3.7 1,522,045,700 1,439,942,488 82,103,212 105.7
4 K-4-18-I GANGGUAN SISTEM PENCERNAAN LAIN-LAIN (RINGAN) 322 4.1 519,628,200 855,102,211 (335,474,011) 60.8
5 J-4-21-I GEJALA, TANDA DAN DIAGNOSIS SISTEM PERNAFASAN LAIN-LAIN (RINGAN) 274 4.7 847,704,000 1,020,618,730 (172,914,730) 83.1
6 N-4-10-I TUMOR GINJAL & SALURAN URIN & GAGAL GINJAL (RINGAN) 224 3.5 839,715,800 785,373,453 54,342,347 106.9
7 M-4-17-I MASALAH BAGIAN PUNGGUNG/PINGGANG BELAKANG (RINGAN) 208 3.1 882,930,500 797,418,317 85,512,183 110.7
8 G-4-14-I KECEDERAAN PEMBULUH DARAH OTAK DENGAN INFARK (RINGAN) 195 4.8 1,099,966,500 949,859,281 150,107,219 115.8
9 U-4-11-I DYSEQUILIBRIUM (RINGAN) 175 3.4 304,684,800 452,167,497 (147,482,697) 67.4
10 E-4-10-I PENYAKIT KENCING MANIS & GANGGUAN NUTRISI/ METABOLIK (RINGAN) 167 4.6 681,504,300 592,627,350 88,876,950 115.0
11 L-1-50-I PROSEDUR PADA PAYUDARA (RINGAN) 167 4.1 1,208,166,500 1,623,879,026 (415,712,526) 74.4
12 C-4-13-I KEMOTERAPI (RINGAN) 159 2.8 355,923,000 779,290,384 (423,367,384) 45.7
13 N-1-40-I PROSEDUR PADA URETRA DAN TRANSURETRA (RINGAN) 139 4.2 1,227,232,600 1,414,564,809 (187,332,209) 86.8
14 Z-4-12-I FAKTOR-FAKTOR YANG MEMPENGARUHI STATUS KESEHATAN LAIN-LAIN (RINGAN) 137 4.7 288,749,500 3,745,720,590 (3,456,971,090) 7.7
15 L-1-40-I PROSEDUR PADA KULIT, JA(RINGAN) BAWAH KULIT DAN PAYUDARA (RINGAN) 135 3.4 752,092,600 1,018,056,078 (265,963,478) 73.9
16 A-4-14-I PENYAKIT INFEKSI BAKTERI DAN PARASIT LAIN-LAIN (RINGAN) 127 5.4 333,920,300 457,552,747 (123,632,447) 73.0
17 I-4-17-I HIPERTENSI (RINGAN) 123 4.0 268,419,600 358,807,109 (90,387,509) 74.8
18 N-4-13-I BATU URIN (RINGAN) 108 3.6 405,470,400 332,825,538 72,644,862 121.8
19 C-4-13-II KEMOTERAPI (SEDANG) 104 3.5 454,389,200 671,434,936 (217,045,736) 67.7
20 O-6-13-II PERSALINAN VAGINAL (SEDANG) 100 2.8 213,259,400 519,929,308 (306,669,908) 41.0
20 Besar INACBG Selisih PositifContoh
RAWAT INAP
Kode INA-
No Deskripsi Kode INA-CBG Jumlah
CBG ALoS Tarif INA-CBG Tarif Riil RS Selisih %
Kasus
1 2 3 4 5,0 6 7 8 9
1 H-1-30-I PROSEDUR LENSA DAN INTRA OKULER (RINGAN) 210 3,0 1.809.298.600 1.564.059.166 245.239.434 115,7
2 H-1-20-I PROSEDUR EKSTRAOKULER DAN ORBITA (RINGAN) 26 2,5 324.249.100 125.357.085 198.892.015 258,7
3 P-8-17-I NEONATAL, BBL > 2499 GR TANPA PROSEDUR MAYOR (RINGAN) 84 3,8 327.947.700 135.194.192 192.753.508 242,6
4 V-1-12-I PROSEDUR PADA SKROTUM DAN PROSTAT KOMPLEK-MODERAT (RINGAN) 65 3,3 659.342.600 466.665.839 192.676.761 141,3
5 M-4-17-I MASALAH BAGIAN PUNGGUNG/PINGGANG BELAKANG (RINGAN) 363 2,6 1.535.998.200 1.346.072.943 189.925.257 114,1
6 E-4-10-I PENYAKIT KENCING MANIS & GANGGUAN NUTRISI/ METABOLIK (RINGAN) 218 4,8 879.427.400 766.758.795 112.668.605 114,7
7 G-4-14-I KECEDERAAN PEMBULUH DARAH OTAK DENGAN INFARK (RINGAN) 209 4,9 1.182.707.500 1.085.951.256 96.756.244 108,9
8 G-4-14-II KECEDERAAN PEMBULUH DARAH OTAK DENGAN INFARK (SEDANG) 85 5,7 660.088.800 563.454.758 96.634.042 117,2
9 G-4-25-I GEGAR OTAK (RINGAN) 93 3,0 261.534.600 168.101.030 93.433.570 155,6
10 N-4-13-I BATU URIN (RINGAN) 104 4,0 396.179.600 315.714.048 80.465.552 125,5
11 I-4-20-I ANGINA PEKTORIS DAN NYERI DADA (RINGAN) 53 4,1 262.764.400 182.896.119 79.868.281 143,7
12 I-1-17-I LIGASI DAN STRIPPING PEMBULUH DARAH VENA (RINGAN) 9 3,6 137.628.400 61.656.261 75.972.139 223,2
13 P-8-13-I NEONATAL, BBL 2000 - 2499 GR TANPA PROSEDUR MAYOR (RINGAN) 27 5,7 151.196.200 78.557.218 72.638.982 192,5
14 A-4-15-I INFEKSI HIV (RINGAN) 7 6,1 103.942.700 33.510.558 70.432.142 310,2
15 B-4-13-I GANGGUAN HATI LAIN-LAIN (RINGAN) 67 5,2 313.487.400 247.177.068 66.310.332 126,8
16 M-1-70-I PROSEDUR LUTUT DAN TUNGKAI BAWAH SELAIN KAKI (RINGAN) 30 5,0 527.268.600 478.714.508 48.554.092 110,1
17 B-4-14-I GANGGUAN SALURAN EMPEDU LAIN-LAIN (RINGAN) 31 4,6 144.343.500 98.334.520 46.008.980 146,8
18 A-4-15-II INFEKSI HIV (SEDANG) 4 8,5 80.464.700 37.435.700 43.029.000 214,9
19 G-4-14-III KECEDERAAN PEMBULUH DARAH OTAK DENGAN INFARK (BERAT) 33 6,5 338.468.500 296.480.290 41.988.210 114,2
20 N-1-12-III MEMBUAT BARU, MEREVISI DAN MEMINDAHKAN ALAT DIALISIS (BERAT) 13 8,2 270.278.000 228.399.131 41.878.869 118,3
20 Besar INACBG Selisih Negatif Contoh
RAWAT INAP
Kode INA-
No Deskripsi Kode INA-CBG Jumlah
CBG ALoS Tarif INA-CBG Tarif Riil RS Selisih %
Kasus
1 2 3 4 5,0 6 7 8 9
SEX DISCHARGE_STATUS
DIAGLIST PROCLIST SL
1 1 I11.0;I25.9 - I
2 1 I12.0;I25.1 39.95 I
1 1 I13.1;I20.0 - II
SEX DISCHARGE_STATUS
DIAGLIST PROCLIST LOS SL
2 1 I11.0;I63.8 87.03 III
1 1 I11.0;I63.8 87.03 III
1 1 I13.2;E11.9;K85.8;K92.0;I63.8 87.03 III
2 3 I10;I69.4;R63.0 - I
Potensi Up Coding
Diagnosis Carsinoma + J90 : Pleural Effusi
SEX DISCHARGE_STATUS
DIAGLIST PROCLIST SL
2 1 C34.9;E11.9;J90 34.04 III
1 1 C34.9;J90 34.91;90.49 III
2 4 S22.10;C38.4;E87.6;J90 03.09;34.91;93.57 III
1 1 C34.9;C78.6;J90 34.91;54.91 III
1 1 C34.9;J90 34.04 III
2 4 C50.9;J90 - III
1 1 C38.4;J90 34.91 III
1 4 C38.4;D63.0;J90 34.04;99.04 III
1 1 C38.4;J90 34.91 III
1 1 C34.9;J90 34.91 III
2 1 I11.9;C83.3;J90 90.79 III
2 1 C34.9;J90 34.04;34.91 III
2 1 C50.9;J90 34.91 III
1 1 C34.9;J90 34.91 III
1 4 C34.9;J90 87.41 III
1 4 C22.0;J90 88.76 III
2 1 C77.0;C78.2;J90 34.91;90.79 III
1 1 C34.9;J90 34.91 III
1 1 C34.9;C79.8;J90 34.91;90.79 III
1 1 C85.7;D63.0;J90 34.91;90.79 III
Urolithiasis (N20-N23)
ADMISSION_DATE
DISCHARGE_DATE
BIRTH_DATE SEX DISCHARGE_STATUS
DIAGLIST PROCLIST INACBG
07/10/20 09/10/20 10/09/68 1 1 N20.1;N13.2 56.99 N-1-20-II
27/11/20 29/11/20 14/12/97 2 1 N13.2;N20.1 56.31 N-4-13-II
ADMISSION_DATE
DISCHARGE_DATE
BIRTH_DATE SEX DISCHARGE_STATUS
DIAGLIST PROCLIST INACBG
30/09/20 02/10/20 15/04/90 1 1 N21.0;N35.9 58.6;57.0 N-1-40-I
11/12/20 11/12/20 01/07/54 1 1 N21.9;D29.1;I10;N35.9 58.6;90.59 N-4-13-I
Potensi Readmisi
ADMISSION_DATE
DISCHARGE_DATE
DIAGLIST PROCLIST NAMA_PASIEN MRN UMUR_TAHUN
30/12/2019 6/1/2020 I25.1;I21.4 00.66;36.07;90.59;88.72;89.52;89.50;93.96;87.49ADE SAEPUL RUHYAT 716621 64
10/1/2020 12/1/2020 I25.1;A41.9;N18.1;E87.1;E87.6;A09.9 89.50;93.96;90.59;99.18;87.49;89.52 ADE SAEPUL RUHYAT 716621 64
6/4/2020 14/04/2020 C11.9;D63.0;E44.0 99.04;90.59;99.18 DEDE ROCHMAT 392143 65
21/04/2020 27/04/2020 C11.9;D63.0;E43 99.04;90.59;99.18 DEDE ROCHMAT 392143 65
5/1/2020 15/01/2020 L03.1;R57.1;D64.9;N17.9 86.22;83.14;99.04;90.59;99.18 EMIN 430067 62
20/01/2020 27/01/2020 E11.9;A41.9;D64.9 89.52;93.96;87.49;99.04;99.18 EMIN 430067 63
13/02/2020 19/02/2020 E11.7;L03.1;D64.9;R57.1 90.59;99.18;99.04;89.52 EMIN 430067 63
8/1/2020 24/01/2020 G91.0;G03.0;A15.2;E87.1;N17.9 02.34;90.59;99.18;99.21;93.96;87.49;87.03 JIMI WENDI AR 717764 20
28/01/2020 10/2/2020 G91.9;A17.0;G01;A15.2;E87.1 93.96;90.59;99.18 JIMI WENDI AR 717764 20
19/01/2020 23/01/2020 J18.0;G41.9;G40.9;G80.9 90.59;99.18;93.94;93.96;87.49 MUHAMMAD RIZQI 695791 0
27/01/2020 8/2/2020 G04.9;E87.0;E87.6;E86;B37.1;J17.2 87.03;87.49;90.59;99.18;93.96 MUHAMMAD RIZQI 695791 0
20/02/2020 2/3/2020 G41.9;A49.9;B37.0;E44.0 90.59;99.18 MUHAMMAD RIZQI 695791 0
26/03/2020 2/4/2020 I69.3;I21.3;G81.9;R13 99.18;90.59;93.94 PUJIHARNO 728348 64
6/4/2020 12/4/2020 N18.1;K30;A41.9 90.59;99.18;99.60;93.96 PUJIHARNO 728348 64
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