Medical Coding
Automated Medical Coding.
In the complex world of healthcare documentation, billing, and research - where Indian hospitals navigate CGHS, insurance panels, and NABH audits - accurate, standardized medical coding is non-negotiable. Pensieve embeds comprehensive support for global coding standards directly into every clinical workflow, ensuring that diagnoses, procedures, investigations, and observations are captured with precision, consistency, and minimal effort from the moment data is entered via templates or orders. The platform integrates the latest versions of the world's leading terminologies seamlessly across the timeline. ICD-11 (WHO's International Classification of Diseases, 11th Revision) serves as the primary diagnostic coding system, with full hierarchy browsing and polyhierarchical support - allowing a single condition like "post-COVID myocardial injury" to carry multiple parent codes for epidemiology and billing. For immediate compatibility with existing Indian insurance and government schemes that still rely on older systems, ICD-10-CM mapping is provided alongside, auto-suggested during diagnosis entry. As doctors type a diagnosis name in the diagnoses collection or template fields, intelligent search delivers exact matches, synonyms, and related terms from both classifications, complete with code, description, and inclusion/exclusion notes. SNOMED CT (Systematized Nomenclature of Medicine Clinical Terms) powers deeper clinical expressivity. Every diagnosis, symptom entered in templates (fever pattern, dyspnea grade, pain location), finding, or procedure is pre-mapped or auto-mapped to SNOMED concepts, enabling rich semantic interoperability and advanced analytics. This granularity supports the AI differential diagnosis engine, where subtle distinctions - such as "acute exacerbation of COPD" versus "community-acquired pneumonia" - drive more accurate suggestions based on template-entered examination and history data. Laboratory and diagnostic investigations leverage LOINC (Logical Observation Identifiers Names and Codes) universally. Whether a template captures "HbA1c", "Glycosylated Haemoglobin", or regional variations, the system standardizes to the correct LOINC code, ensuring results from any integrated LIS or manual entry are comparable across sites, time, and future US expansions. Reference ranges, specimen types, and units are pulled automatically, with abnormal values flagged consistently. Procedures and interventions draw from multiple standards: CPT (Current Procedural Terminology) and ICD-10-PCS - while maintaining compatibility with Indian classifications. As doctors create orders or template entries for surgeries, injections, or physiotherapy, relevant codes auto-populate with descriptions, reducing coding errors at the point of care. All coding happens contextually and intelligently - never as a separate post-hoc task. Template builder allows administrators to bind fields directly to specific code sets (e.g., a "chief complaint" dropdown pre-loaded with SNOMED subsets for respiratory symptoms). The AI chat agent and CDS engine use these standardized codes to deliver precise, guideline-based recommendations and alerts. For billing and analytics, coded data flows automatically: insurance claims bundle ICD/SNOMED/LOINC-tagged diagnoses and procedures; quality dashboards track disease incidence using standardized definitions. Administrators can customize code set preferences per site - favoring ICD-11 in new Indian units while retaining ICD-10-CM for legacy payers - while the cloud master database updates annually or as WHO/CMS releases new versions, keeping your entire network current without downtime. In Pensieve, medical coding is not an afterthought or a burden on doctors - it is woven invisibly into every template, order, and timeline entry, delivering standardization that ensures clinical accuracy, regulatory compliance, seamless reimbursement, and powerful AI insights.