Optimize clinical notes for ICD-10 accuracy
River reviews your note for diagnosis specificity, HCC capture, E/M support, and coding gaps — and shows you exactly what to add.
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Verified against ICD-10-CM — Live ICD-10-CM code lookup via NLM Clinical Tables
River's ICD-10 Documentation Assistant reviews clinical notes, problem lists, and A/P sections for ICD-10 coding accuracy and documentation completeness. It identifies where diagnoses can be coded to a higher specificity, flags HCC-relevant chronic conditions, checks E/M documentation support, and generates a structured table of findings with specific suggestions for improving documentation.
Poor ICD-10 documentation costs practices revenue through downcoding, missed HCC captures, and claim denials. At the same time, over-coding or undocumented coding creates compliance risk. This tool helps you find the balance — coding to the highest level actually supported by your note, with specific documentation suggestions to close gaps.
Use this after writing a note to catch documentation gaps before the claim is submitted, in pre-bill audits, or as part of physician education and CDI programs.
Why ICD-10 Specificity Matters
ICD-10-CM has over 70,000 codes. Most clinical documentation problems come from using unspecified codes when more specific codes are available and supportable. For example: 'diabetes' might be coded as E11.9 (type 2 DM without complications) when the note actually describes E11.40 (with diabetic neuropathy, unspecified) or E11.65 (with hyperglycemia). Each level of specificity has revenue implications and risk adjustment implications.
HCC (Hierarchical Condition Category) risk adjustment is used by Medicare Advantage, ACA marketplace plans, and some commercial payers to adjust payments based on patient complexity. Chronic conditions like CHF, COPD, diabetes with complications, CKD, and others must be documented and coded every year to count toward the patient's RAF score. Missing HCC documentation means practices are not compensated for caring for complex patients.
E/M documentation for office visits requires supporting medical decision-making (MDM) at the appropriate level. For a 99214, you need moderate MDM: at least 2 of 3 elements (number of problems, data reviewed, risk). AI can quickly review whether your note supports the intended level or where additional documentation would strengthen the claim.
What You Get
Structured table of diagnoses with ICD-10 candidates from NLM Clinical Tables
Specificity gaps identified with specific documentation suggestions
HCC-relevant chronic conditions flagged for proper capture
E/M documentation adequacy assessment
Augmented A/P or coder query format options
Coding disclaimer and verification guidance
How It Works
- 1Paste your clinical notePaste the progress note, A/P section, or problem list
- 2Select review focusChoose specificity, HCC, E/M, medical necessity, or all
- 3AI reviews and generatesRiver extracts diagnoses, looks up ICD-10 candidates, and generates the review
- 4Address the gapsAdd the suggested documentation to your note before submission
Frequently Asked Questions
Does this replace a certified coder?
No. This tool assists documentation review and provides coding suggestions, but final code assignment should be verified by a certified professional coder (CPC) before claim submission. Use this as a first-pass review tool and educational resource.
How does the ICD-10 lookup work?
River uses the NLM Clinical Tables ICD-10-CM API to look up candidate codes for each diagnosis identified in your note. This database is updated annually and reflects current ICD-10-CM codes as used in U.S. healthcare settings.
Can I use this for inpatient coding?
This tool is optimized for outpatient/office visit coding following outpatient ICD-10-CM guidelines (where 'possible/probable' diagnoses are coded to symptom level). For inpatient coding (where principal diagnosis rules differ), results should be interpreted with inpatient coding guidelines in mind.
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