Identification of the patient's diagnosis and/or procedure: This involves identifying the primary reason for the patient's encounter and the subsequent diagnosis and/or procedure. Natural Language Processing - This technique uses artificial intelligence to recognize patterns in the medical record to recommend code sets. The healthcare provider begins documenting the medical procedure or diagnosis at the identification step. It helps healthcare providers to organize and keep track of patients’ health records. Decision Support Systems - This involves using computer-based programs that recommend codes based on the medical record. The International Classification of Diseases (ICD) code is the most widely used classification scheme.
standardized codes
