Tn. Ahmad Santoso
MRN 001223 · Encounter RI-2026-000981 · Rawat Inap · DPJP dr. Budi · LOS 4 hari
Principal Dx
I50.9 CHF
Secondary
E11.9, J18.9?
Procedure
89.52, 88.72
Current CBG
I-4-10-I
Tariff
Rp 8.750.000
Billing
Rp 11.850.000
Evidence
2 strong, 1 weak
Claim Ready
No
Clinical Evidence Readiness
Principal Dx support Strong
DM support Strong
Pneumonia support Weak
Procedure evidence ✅
Resume signed ✅
CDI closed No
Grouper run ✅
Send to claim Blocked
CBG Code
I-4-10-I
Severity
Ringan
Tariff
Rp 8.75M
Billing
Rp 11.85M
Margin
-Rp 3.10M
Risk
Medium
Casemix & CDI Workflow
Episode Closed
29 Mei
Evidence Pull
Auto
Coding Review
Now
CDI Query
Needed
Grouper Run
Done
Claim Ready
Blocked
Send to Claim
-
Recon Feedback
-
Evidence Matrix
| Evidence | Source | Supports | Status |
|---|---|---|---|
| CPPT: sesak, edema, CHF | CPPT DPJP | I50.9 | Strong |
| CXR: cardiomegaly | Radiologi | CHF | Strong |
| Leukosit 15.000 | Lab | Infection marker | Moderate |
| CXR infiltrat bilateral | Radiologi | Pneumonia | Strong |
| Pneumonia final diagnosis | Resume | J18.9 | Missing |
Coding & CDI Review
Principal Dx I50.9
Evidence strong: CPPT + radiologi + terapi diuretik.
Secondary Dx E11.9
HbA1c 8.2 dan riwayat terapi DM.
Secondary Dx J18.9
Evidence klinis ada, tetapi resume belum menyebut pneumonia final.
Grouper Scenario
Dengan pneumonia valid, severity mungkin naik ke I-4-10-II.
Claim readiness
Blocked sampai CDI query closed atau code J18.9 dihapus.
CDI Query
Klarifikasi pneumonia aktif vs CHF exacerbation ke DPJP.
Grouper Simulation
Current: I-4-10-I Rp 8.75M. If supported pneumonia: I-4-10-II Rp 11.2M.
LOS
LOS 4 hari, trim point 7 hari, outlier: No.
Costing
Estimated cost Rp 9.9M, margin -Rp 1.15M.
Claim
Ready only after secondary diagnosis support is resolved.
Audit
Coding changes, grouper runs, and CDI answers are logged.