Watch Out for Copy-Forward and Imported Information
Question: After reading the Revenue Cycle Insider article, “Learn What You Can — and Can’t — Code From Ambient AI Notes,” I was wondering what we should do if the artificial intelligence (AI) adds information from elsewhere in the patient’s record. Can you advise? Ohio Subscriber Answer: As ambient AI tools continue to evolve, some platforms do more than simply capture conversations. Depending on how they are configured, they may also pull information from prior notes, problem lists, medication lists, or other portions of the electronic health record (EHR). While these features can improve efficiency, they can also create coding challenges. Diagnoses that appear in the assessment or history may not necessarily reflect conditions that were evaluated, monitored, assessed, treated, or otherwise addressed during the current encounter. Example: An AI-generated note may include chronic obstructive pulmonary disease (COPD), depression, or chronic kidney disease (CKD) because those conditions were carried forward from a previous visit. If the provider did not address those conditions during the current encounter and the documentation does not support reporting them, they may not be appropriate for the claim. What you can do: When reviewing AI-generated documentation, pay close attention to where diagnoses originated from and whether they were actively managed during the encounter. The presence of a condition in the note does not automatically mean it is reportable. As with any documentation source, coding decisions should be based on applicable coding guidelines and the documentation supporting the services provided during that specific visit. This review process becomes especially important as healthcare organizations increasingly rely on technologies that combine ambient documentation with information already contained in the medical record. Careful evaluation can help prevent coding errors, reduce audit risk, and support the accuracy of the health record. Suzanne Burmeister, BA, MPhil, Medical Writer and Editor
