Clinical Documentation Integrity

Find the documentation gap. Ask the physician. Close the loop.

The same AI pass that codes the chart reviews its documentation against the clinical evidence. The gaps worth a specialist's time become prioritised CDI opportunities, a neutral query is drafted from the evidence, and the physician's answer flows back into the coding - with a coder checking every change.

4
review categories
well supported, needs clarification, conflicting, possibly missing
6
opportunity categories
ranked high, medium or low, with the evidence behind each
1
answer per query
given once by the physician, and recorded
0
logins for the physician
a secure link that expires and can be revoked

Three AI agents, each with one job

Each agent sees only what its task needs, and a CDI specialist stands between every step.

The review agent

Reads the de-identified chart while it is coded and sorts every documentation finding into four categories, each with verbatim excerpts located in the document.

The query agent

Drafts a neutral, non-leading clarification from the smallest context - the opportunity and its excerpts, never the whole chart - for the specialist to edit and send.

The reconciliation agent

Reads the physician's answer once and says whether it changes the coding. Deterministic safety rules then decide what may change, and a coder reviews it.

Clinical documentation, from the first word to the final DRG

Six steps from the doctor's words to a coded, audited and grouped chart, with people reviewing the results along the way.

  1. DeepMed Dictate

    Dictate and approve: clinical dictation 

    Dictate or record the consultation with consent; the doctor approves the draft.

    Exports PDF, JSON or FHIR R4
  2. DeepMed Platform

    Read and protect: how a chart is read 

    Scans become text, and identifiers are masked before any AI sees them.

  3. DeepMed Platform AI-Assisted Coding

    Code: AI-assisted coding 

    Suggested codes arrive with the passage behind them, for the coder to accept.

  4. DeepMed Platform Coding Audit

    Audit: coding audit 

    A second AI pass scores the coding and proposes changes for the auditor.

  5. DeepMed PlatformThis page CDI

    Clarify: CDI and physician queries 

    Documentation gaps become neutral, non-leading physician queries.

  6. DeepMed Platform DRG Grouping

    Group: DRG grouping 

    A rules-based grouper assigns the DRG, final when the chart is locked.

CDI that ends in an answer, not a note

From the first finding to the reconciled code, every step is recorded and every change is a person's decision.

1
Documentation review

What the documentation does and does not say

Every finding lands in one of four categories - well supported, needs clarification, conflicting, possibly missing - with how it is documented now, what a clarification would settle, and the excerpts that put it there. View evidence highlights them in the document.

Four review categoriesVerbatim evidenceHighlighted in the document
2
CDI opportunities

The findings worth a specialist's time

Findings that deserve attention become prioritised opportunities - high, medium or low - with the clinical indicators, what is documented now and the gap between them.

Six opportunity categoriesPriority and confidenceClinical indicators
3
Query drafting

A question a physician can answer in a minute

A draft written from the opportunity and its excerpts alone - neutral and non-leading by construction. The specialist edits it, regenerates it or saves it.

Non-leading by designSmallest contextEdit, regenerate, save
4
Send and answer

The physician answers once, through a secure link

The query is sent to the chart's doctor or another doctor as an exact snapshot that can no longer be edited. The physician opens a link with no login, sees what was sent and its evidence, picks an option or writes a comment, and answers once.

Secure link, no loginExpires, can be revokedOne answer, recorded
5
Reconciliation

The answer comes back into the coding

The reconciliation agent is asked once whether the answer changes the coding. Then deterministic rules take over:

  • "Unable to determine" establishes nothing
  • A condition the physician negated is never suggested
  • The principal diagnosis is never changed automatically
  • A coder's earlier accept or reject is never overwritten
  • Anything new is flagged review required for a coder to accept

Every query leaves a trail

The CDI workspace sits beside the document, and every query carries its own timeline - who drafted it, when it was sent and viewed, what the physician said and what changed as a result.

  • Suggested CDI, Auto CDI or No CDI - set per chart
  • A CDI Specialist role with its own work list and notifications
  • Resolve, close or cancel a query, with a reason
  • The CDI workspace shown only to the people who do the work
  • Queries already sent finish normally, whatever the chart's mode

The trail a query leaves

Drafted - from opportunity #418, three evidence excerpts
Sent - an exact snapshot, no longer editable
Viewed - the link was opened
Responded - one option chosen, comment recorded
Reconciled - one suggestion added, one flagged for review

Illustration - a fictional chart.

CDI and DRG, kept properly apart

When DRG grouping needs a clinical detail the documentation leaves unclear, the DRG tab offers Clarify through CDI. It links an existing opportunity or opens a new one - and the query never mentions the DRG, a weight or reimbursement.

  • The DRG item shows the linked opportunity and its query status
  • While CDI is open, an accepted DRG is shown as provisional
  • A physician's response changes the DRG only once a coder accepts the reconciled code
  • With No CDI, the request goes to the chart's owner and supervisors - never around CDI

New: DRG Grouping

Every coded inpatient chart grouped into its DRG by a rules-based grouper, reviewed by your DRG specialist and made final when the chart is locked.

Explore DRG Grouping

Watch the queries write themselves

A demo account opens the whole platform - upload a chart, review the documentation findings, and draft your first physician query from the evidence.

Start a Free Demo Talk to us first
Top