AI agent for medical coders
Coding Query Resolution Agent
Resolve documentation gaps and code only what is supported.
What it does
A coder who finds unclear documentation sends a query to the provider, and the answer can take weeks or get lost. This agent reads encounters where the documentation does not support a code, such as a diagnosis without the clinical support. It drafts a query that follows compliant rules: non-leading, with the clinical facts and options. It tracks responses and reminds the provider. When an answer arrives it checks whether it supports the code. If the answer is unclear, it drafts a follow-up query instead of changing the code. The coder approves the final codes. Edge case: a query that reads like it suggests a diagnosis is rewritten to ask open-ended options.
How it works
Follow the arrows from top to bottom. The orange dashed arrow is the loop: when a check fails, the agent goes back and tries again.
Read the steps as a list
- Encounter has a documentation gap
- Read the notes and the assigned codes
- Find the code the notes do not support
- Draft a compliant, non-leading query
- Is the query free of leading language and does it list clinical facts?If not: Rewrite it with open-ended options. Back to step 3.
- Send the query and track the response
- Did the provider answer within the time limit?If not: Send a reminder, then escalate to the coding lead. Back to step 5.
- Check whether the answer supports a code
- Is the answer clear?If not: Draft a follow-up query instead of changing the code. Back to step 4.
- Coder approves the final codesThe agent waits here for your OK.
- Codes updated and query closed
How it decides
It queries only when documentation does not support a code, and it changes a code only from a clear provider answer.
- Query when the notes do not support the code
- Never suggest a diagnosis in the query
- Remind after 3 days and escalate after 7
- Keep the query and answer in the record
Make it yours
Every agent is a starting point. You choose these settings for your own situation.
- Reminder timing (default 3 and 7 days)
- Query template
- Who escalates
- Codes that need queries
What keeps you in control
It always asks you first
- Coder approves final codes and queries
Hard limits
- Never change a code from an unclear answer
- Never send a leading query
It stops when
- Done: final codes match the documentation
- Stop: the provider declines to answer and the coder uses the supported codes
Set it up
We guide you through the set-up, step by step
Members get the full set-up guide for this agent. No technical skills needed: you copy, paste and upload.
- One set of instructions to paste into your AI, with the clicks for ChatGPT, Claude, Microsoft 365 Copilot, Gemini and Grok
- The agent then walks you through connecting your own data, one source at a time
- A downloadable copy with the flow chart, the rules and the full guide
