Reviewing AI-suggested ICD-10 codes without slowing down

A suggested code is a starting point. Charted shows each ICD-10 suggestion next to the sentence it came from, so the check comes down to one test: does what was said support the code at the level of detail the code claims?

That test covers the note as much as the code. Only the signed note goes into the patient's record, and the official coding guidelines base code assignment on the documentation of the provider legally accountable for the diagnosis. If a code's support exists only in the transcript, no one reading the chart later will see it.

A three-step check

1. Read the evidence sentence, not the code description. The description tells you what the code claims, and the sentence tells you what was said. Tap the sentence to jump to that moment in the transcript.

2. Check specificity, such as laterality, encounter type and whether a condition is controlled, wherever the code depends on it.

3. Remove anything that was mentioned but not addressed, like a chronic problem that came up in passing.

In our pilot, clinicians changed about one suggestion in eight, most often to add laterality or to switch an initial encounter to a subsequent one.

Laterality

Some ICD-10-CM codes specify left, right or bilateral. When the record doesn't identify the side, the guidelines call for the code for the unspecified side, and they add that those codes should rarely be used, for example when the documentation isn't enough to determine the side and clarification isn't possible.

In the room, the side is usually obvious and often goes unspoken. You examine the left knee and say "this knee." A gesture doesn't reach the transcript, so the evidence sentence can't support a side. Say the side out loud during the exam, or type it into the note before you accept the code.

Initial or subsequent encounter

Most injury categories in chapter 19 take a 7th character: A for initial encounter, D for subsequent encounter and S for sequela, with extra values for traumatic fractures. The labels sound like they track your first meeting with the patient, but the guidelines tie them to treatment. A applies to each encounter where the patient is receiving active treatment. D applies after active treatment is complete, when the patient is receiving routine care during the healing or recovery phase. A new or different provider along the way doesn't change which one applies.

So a patient you are meeting for the first time can still need D, if active treatment is finished and your visit is routine care while the injury heals. For aftercare of an injury, the guidelines say to use the injury code with D rather than an aftercare Z code. If treatment status never comes up, say where things stand so the draft has a sentence to work from.

Mentioned but not addressed

For outpatient visits, the guidelines say to code all documented conditions that coexist at the time of the visit and require or affect patient care, treatment or management. Conditions that were treated before and no longer exist aren't coded, although a history code can be added when the past condition affects current care.

Visit conversations wander. A patient mentions their asthma while you treat an ankle sprain, and a suggestion appears for it. If the asthma didn't change what you did or decided, remove the code. If it did, keep the code and make sure the assessment or plan says how.

Fix the note, then accept

When a code needs a detail that wasn't said aloud, add it to the note first, then accept the code. Accepting first leaves a code more specific than the documentation behind it, and that code won't hold up if the chart is audited. Nothing is coded until you accept it. On plans with a direct EHR connection, accepted codes go to the visit diagnoses field with the signed note.

Questions we get

Can a nurse's documentation supply the side?

Yes. Laterality is one of the listed exceptions: when the patient's provider doesn't document the side, it can be taken from other clinicians' documentation in the record. The diagnosis itself still has to be documented by you, and if the record conflicts on the side, the guidelines say to query you.

What if the evidence sentence itself is wrong?

Check that moment in the transcript, correct the note if the draft repeated the error, then change or remove the code to match.