Implementation of a Medical Coding Mentorship Program to Reduce BPJS Health Insurance Pending Claims at Sandi Karsa Hospital, Makassar

Agustina; Lilik Meilany; Asriyanti; Rosana Dwiyanti Putri

doi:10.35816/abdimaspolsaka.v5i1.256

Authors

Agustina D3 Medical Records and Health Information Study Program, STIKES Panakkukang Makassar, South Sulawesi
Lilik Meilany D3 Medical Records and Health Information Study Program, STIKES Panakkukang Makassar, South Sulawesi
Asriyanti D3 Medical Records and Health Information Study Program, STIKES Panakkukang Makassar, South Sulawesi
Rosana Dwiyanti Putri D3 Medical Records and Health Information Study Program, STIKES Panakkukang Makassar, South Sulawesi

DOI:

https://doi.org/10.35816/abdimaspolsaka.v5i1.256

Keywords:

medical coding, mentoring program, pending claims, BPJS Health, hospital claim management

Abstract

Background: In Indonesia’s National Health Insurance (JKN) system, the accuracy of medical coding plays a critical role in determining claim approval and reimbursement through the Indonesia Case Base Groups (INA-CBGs) payment mechanism. Inaccurate coding of diagnoses and procedures often results in pending BPJS Health claims, leading to delayed payments and increased administrative burden for hospitals. This community service activity aimed to implement and evaluate a mentoring program designed to improve medical coding practices and reduce pending BPJS Health claims at Sandi Karsa Hospital, Makassar.

Methods: The program was conducted from August to October 2025 using a participatory and problem-solving approach. The activities included initial assessment of pending claims, theoretical training on ICD-10 and ICD-9-CM coding principles, case-based simulations using actual medical records, direct on-site mentoring during coding processes, and the development of a Standard Operating Procedure (SOP) for medical coding. Program evaluation was performed by comparing the number of pending claims related to coding errors before and after the intervention and by observing improvements in coding practices.

Results: Prior to the intervention, 85 cases of pending claims were identified as being caused by coding rule errors. After the mentoring program was implemented, the number decreased to 34 cases, representing a reduction of approximately 60%. In addition, qualitative improvements were observed in the consistency of determining principal and secondary diagnoses, the accuracy of ICD-10 and ICD-9-CM code selection, and the overall quality of claim documentation.

Conclusion: The mentoring-based intervention effectively improved medical coding accuracy and reduced BPJS pending claims at the hospital. Continuous training, regular coding audits, and the implementation of standardized coding procedures are recommended to sustain these improvements and support more efficient hospital claim management

References

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

Anton Susanto, Galih Maheswari Candraningtyas, & Agus Trijono. (2025). Akurasi Pengkodean Diagnosis dan Prosedur Medis serta Implikasinya terhadap Klaim JKN di RSUD Pandan Arang. Jurnal Ilmiah Kedokteran Dan Kesehatan, 4(3), 306–317. https://doi.org/10.55606/klinik.v4i3.4610

Arkoudis, N.-A., Tavernaraki, K., Moschovaki-Zeiger, O., Balomenos, V., Velonakis, G., Papakonstantinou, O., Filippiadis, D., Alexopoulou, E., Kelekis, N., & Spiliopoulos, S. (2025). Education and training satisfaction among radiology residents: Insights from a national survey. European Journal of Radiology, 189, 112191. https://doi.org/10.1016/j.ejrad.2025.112191

Cromeens, M. G., Knafl, K., Robinson, W. R., Carey, E. T., Haji-Noor, Z., & Thoyre, S. (2024). Endometriosis and Disability: Analysis of Federal Court Appeals of Social Security Disability Insurance and Supplemental Security Income Claims by Individuals Suffering From Endometriosis. Women’s Health Issues, 34(3), 221–231. https://doi.org/10.1016/j.whi.2023.11.008

Daroedono, E., Aurellita, N., Savero, I., Sirait, G. P., Imanuel, R., & Kuheba, E. G. (2025). The Curative Role of the Main Primary Health Facility in Indonesia: Analyzing Patient Visits at a Single PUSKESMAS with a Focus on General and Maternal-Child Health Clinics. Asian Journal of Research in Medical and Pharmaceutical Sciences, 14(2), 68–78. https://doi.org/10.9734/ajrimps/2025/v14i2306

Indawati, L. (2019). Analisis Akurasi Koding Pada Pengembalian Klaim BPJS Rawat Inap Di RSUP Fatmawati Tahun 2016. Jurnal Manajemen Informasi Kesehatan Indonesia, 7(2), 113. https://doi.org/10.33560/jmiki.v7i2.230

Istianingsih, N., Mudiono, D. R. P., Rachmawati, E., & Suyoso, G. E. J. (2025). Analysis of Factors Causing Pending BPJS Inpatient Claims at dr. H. Koesnadi General Hospital, Bondowoso. International Journal of Healthcare and Information Technology, 2(2), 89–99. https://doi.org/10.25047/ijhitech.v2i2.6165

Lam, B. C., Chen, J., & Ku, H. B. (2025). Biopower, governmentality and the making of health inequities of migrant domestic workers in Hong Kong. Social Science & Medicine, 383, 118449. https://doi.org/10.1016/j.socscimed.2025.118449

Mmonu, N., Kamdar, N., Roach, M., Sarma, A., Makarov, D., Zabar, S., & Breyer, B. (2024). Disparities in the Delivery of Prostate Cancer Survivorship Care in the USA: A Claims-based Analysis of Urinary Adverse Events and Erectile Dysfunction Among Prostate Cancer Survivors. European Urology Open Science, 62(2), 26–35. https://doi.org/10.1016/j.euros.2024.01.003

Paoli, L., & Joseph Cox, L. T. (2024). Across the spectrum of legality: The market activities of influencers specialized in steroids and other performance and image enhancing drugs. International Journal of Drug Policy, 123, 104246. https://doi.org/10.1016/j.drugpo.2023.104246

Patel, V., Kalita, A., Furtado, K. M., Mor, N., Bhadada, S., Albert, S., Ashraf, H., Balsari, S., Bhushan, I., Chandru, V., Chatterjee, M., Chaturvedi, S., Dharmaraju, R., Gupta, A., Mazumdar-Shaw, K., Menon, G. I., Mukherji, A., Muttreja, P., Nambiar, A., … Khanna, T. (2026). The Lancet Commission on a citizen-centred health system for India. The Lancet, 407(10526), 388–468. https://doi.org/10.1016/S0140-6736(25)02169-5

Sari, A. N., Syaodih, E., & Lestari, Y. (2025). Evaluasi Implementasi Pengelolaan Piutang BPJS di BLUD Rumah Sakit Umum Daerah Provinsi Nusa Tenggara Barat. Journal of Business, Finance, and Economics (JBFE), 6(2), 261–270. https://doi.org/10.32585/jbfe.v6i2.7697

Situmorang, B. A., Aziz, A., & Hutapea, F. (2025). Analysis of Factors Causing Pending BPJS Health Claims for Inpatients at Kartika Husada Setu Hospital in 2024. International Journal of Business, Law, and Education, 6(1), 549–555. https://doi.org/10.56442/ijble.v6i1.1051

Stevens, P. E., Ahmed, S. B., Carrero, J. J., Foster, B., Francis, A., Hall, R. K., Herrington, W. G., Hill, G., Inker, L. A., Kazancıoğlu, R., Lamb, E., Lin, P., Madero, M., McIntyre, N., Morrow, K., Roberts, G., Sabanayagam, D., Schaeffner, E., Shlipak, M., … Levin, A. (2024). KDIGO 2024 Clinical Practice Guideline for the Evaluation and Management of Chronic Kidney Disease. Kidney International, 105(4), S117–S314. https://doi.org/10.1016/j.kint.2023.10.018

Susilo, D., Wulandari, L. P. L., Sukmayeti, E., Asante, A., Jan, S., Thabrany, H., Tangcharoensathien, V., Wiseman, V., & Liverani, M. (2025). Can Indonesia achieve universal health coverage? Organisational and financing challenges in implementing the national health insurance system. SSM - Health Systems, 5(1), 100138. https://doi.org/10.1016/j.ssmhs.2025.100138

Tresh, A. S., Del Giudice, F., Li, S., Basran, S., Belladelli, F., De Berardinis, E., Asero, V., Ferro, M., Tataru, S., Maria Busetto, G., Falagario, U., Autorino, R., Crocetto, F., Barone, B., Pradere, B., Moschini, M., Mari, A., Krajewski, W., Nowak, Ł., … Chung, B. I. (2024). The Impact of Venous Thromboembolism on Upper Tract Urothelial Carcinomas Undergoing Open or Minimally Invasive Radical Nephroureterectomy in the USA: Perioperative Outcomes and Health Care Costs from Insurance Claims Data. European Urology Focus, 10(2), 317–324. https://doi.org/10.1016/j.euf.2024.02.004

Tubishat, M., Tbaishat, D., Al-Zoubi, A. M., Hraiz, A.-E., & Habib, M. (2025). Leveraging evolutionary algorithms with a dynamic weighted search space approach for fraud detection in healthcare insurance claims. Knowledge-Based Systems, 317(6), 113436. https://doi.org/10.1016/j.knosys.2025.113436

Vaccari, E. M., Agre, K. E., Williams, T. J., Krempely, K. E., Ting, Y.-L., & Esplin, E. D. (2026). Insurance Coverage Of Cardiomyopathy Genetic Testing Stratified By Insurance Types And Cardiomyopathy Subtype. Journal of Cardiac Failure, 32(1), 200. https://doi.org/10.1016/j.cardfail.2025.11.068

Winarsih, S. A., Widjanarko, B., & Agushybana, F. (2024). The Impact of Electronic Medical Records on BPJS Claims and Physician Performance. Jurnal Indonesia Sosial Teknologi, 5(8), 3678–3690. https://doi.org/10.59141/jist.v5i8.1207