Problem Statement

Medicare designates certain procedures as inpatient-only, so the claim is paid only if the patient is in inpatient status. These tend to be high-cost cases. An inpatient-only procedure can be performed on a patient in observation or extended recovery when the case was never booked under the matching code. It is often not caught until coding, after the patient has been discharged in outpatient status, and by then the denial or write-off can't be avoided.

Automation Solution

This automation pulls the daily observation and extended-recovery report, reads every operative note on each encounter, and uses a large language model (LLM) to compare them against the inpatient-only procedure list, matching on meaning rather than exact wording. Cases scoring 80% or higher are emailed to the Clinical Documentation Review Unit (CDRU), which confirms the match and changes the patient class to inpatient before discharge.