Quick check
Guess first, no penalty. An outpatient note says "probable pneumonia, chest X-ray ordered". The AI suggests the pneumonia code. Under the ICD-10-CM outpatient guidelines, what gets coded?
ICD-10-CM is the US system of diagnosis codes. Its official guidelines (FY 2027) say: "Code assignment is based on the documentation by the patient's provider" (Section I.B.14).
The setting changes the rule
For outpatient visits, Section IV.H says: "Do not code diagnoses documented as 'probable', 'suspected,' 'questionable,' 'rule out,'" and instead code "to the highest degree of certainty for that encounter/visit". For inpatient admissions to certain hospitals, Section II.H says to code an uncertain diagnosis "as if it existed or was established".
An AI tool may not know the setting, or may follow the inpatient pattern on an outpatient note. So check two things for every suggestion: the words in the note, and the setting of the visit.
Outpatient visit. Note: "cough and fever for 3 days, probable
pneumonia, chest X-ray ordered."
AI suggestion: pneumonia. Not coded: "probable", outpatient (IV.H).
Coded instead: the documented cough and fever.
If a later note confirms pneumonia, that visit is coded from it.Fill the gaps
Fill the gaps in the same check.
Check
AI suggestion: pneumonia. Not coded: . Coded instead: . If a later note confirms pneumonia, .
Try it
Your steps, about 2 minutes
- 1.Add line 2 to your Record check sheet: "Check the note's words and the visit setting before accepting any AI code." Then find one note with "probable" or "rule out" and decide what the outpatient rule allows.2 min