ICD-10 & CPT Coding Assistant

---

name: icd10-cpt-coding-assistant

description: 'Automatically recommend ICD-10 diagnosis codes and CPT procedure codes

from clinical notes. Trigger when: user provides clinical notes, patient encounter

summaries, discharge summaries, or asks for medical coding assistance. Use for healthcare

providers, medical coders, and billing professionals who need accurate code recommendations.'

version: 1.0.0

category: Clinical

tags: []

author: AIPOCH

license: MIT

status: Draft

risk_level: Medium

skill_type: Tool/Script

owner: AIPOCH

reviewer: ''

last_updated: '2026-02-06'

---

# ICD-10 & CPT Coding Assistant

A medical coding assistant that parses clinical notes and recommends appropriate ICD-10 diagnosis codes and CPT procedure codes with confidence scoring.

Overview

This skill analyzes clinical documentation to extract relevant medical information and map it to standardized coding systems:

Technical Difficulty: **HIGH** ⚠️

> **⚠️ HUMAN REVIEW REQUIRED**: Medical coding directly impacts billing, reimbursement, and clinical documentation. All recommendations must be verified by a certified medical coder or healthcare provider.

Usage

python scripts/main.py --input "clinical_note.txt" [--format json|text]

Or use programmatically:

from scripts.main import CodingAssistant

assistant = CodingAssistant()
result = assistant.analyze("Patient presents with acute bronchitis...")
print(result.icd10_codes)
print(result.cpt_codes)

Parameters

| Parameter | Type | Default | Required | Description |

|-----------|------|---------|----------|-------------|

| `--input`, `-i` | string | - | Yes | Path to clinical note file |

| `--format`, `-f` | string | json | No | Output format (json, text) |

| `--output`, `-o` | string | stdout | No | Output file path |

| `--confidence-threshold` | float | 0.7 | No | Minimum confidence score (0.0-1.0) |

| `--include-alternatives` | flag | false | No | Include alternative code suggestions |

Input Format

Accepts clinical notes in various formats:

Output Format

ICD-10 Recommendations

{
  "icd10_codes": [
    {
      "code": "J20.9",
      "description": "Acute bronchitis, unspecified",
      "confidence": 0.92,
      "evidence": ["cough for 5 days", "wheezing on exam"],
      "alternatives": ["J20.0", "J44.9"]
    }
  ]
}

CPT Recommendations

{
  "cpt_codes": [
    {
      "code": "99213",
      "description": "Office visit, established patient, moderate complexity",
      "confidence": 0.85,
      "evidence": ["detailed history", "low complexity decision making"],
      "time": "20 minutes"
    }
  ]
}

Confidence Scoring

Limitations

1. **No Medical Advice**: This tool does not provide clinical advice or diagnoses

2. **Coding Complexity**: Cannot handle all coding nuances (comorbidities, sequencing, modifiers)

3. **Regional Variations**: May not account for payer-specific coding requirements

4. **Updates**: Code sets may not reflect the latest annual updates

References

See `references/` folder for:

Safety & Compliance

Dependencies

Risk Assessment

| Risk Indicator | Assessment | Level |

|----------------|------------|-------|

| Code Execution | Python/R scripts executed locally | Medium |

| Network Access | No external API calls | Low |

| File System Access | Read input files, write output files | Medium |

| Instruction Tampering | Standard prompt guidelines | Low |

| Data Exposure | Output files saved to workspace | Low |

Security Checklist

Prerequisites

# Python dependencies
pip install -r requirements.txt

Evaluation Criteria

Success Metrics

Test Cases

1. **Basic Functionality**: Standard input → Expected output

2. **Edge Case**: Invalid input → Graceful error handling

3. **Performance**: Large dataset → Acceptable processing time

Lifecycle Status

- Performance optimization

- Additional feature support