Wiki assessment vs. diagnosis (AI note writer)

[Brenda1973]

I need advice on how to approach this issue with my providers. We recently started using AI note writer, which seems to pick up words that providers are saying and applies them to the note. 2 examples below:
As a coder I have always used the assessment to determine the diagnosis to be applied to the claim. These notes are confusing as the assessment is not matching the diagnosis that is documented in bold print from the AI note writer and also that is the diagnosis that is being applied to the claim. I will query providers as to verify which diagnosis to use. Am I wrong when I state that as a coder, we are trained in use the assessment as the diagnosis? Please advise.

 

[jkyles]

Hi there, If it produces a signs/symptom diagnosis when the provider has given a specific diagnosis, that sounds like a problem with the software, not anything you or the providers are doing.

I think you need to show your providers that these are the results that it is generating right away. Aside from the need for accurate coding, if it always or usually defaults to a signs/symptom diagnosis you're going to encounter payment issues.

 

[Pam Warren]

I agree with jkyles above, but also want to point out that as a coder, you are able to abstract a final diagnosis from the entire note, not just the assessment.