How-to-Construct-Medical-Record-Prompts-for-NLP-and-AI-Models (2) (2).pptx

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1. How to Construct Medical Record Prompts for NLP and AI Models Creating prompts for NLP and AI to extract relevant data from medical records accurately requires consideration of various factors. To ensure that AI models provide the most appropriate CPT and ICD-10-CM codes for billing and reporting purposes, we need to be explicit, comprehensive, and set general length goals for responses. The following are some useful tips to bear in mind when constructing effective prompts.

2. Specify Actions for AI to Achieve Goals Action Oriented Clearly specify the desired outcome and intended objective . Direct NLP and AI models to identify the ICD-10-CM code for the primary diagnosis.

3. Use Suitable Language Complexity Task Complexity Simple queries can be casual, while complex tasks require structured, detailed prompts that break down the records into specific tasks.

4. Leave No Room for Misinterpretation 1 Specificity Identify the exact ICD-10-CM, CPT code for the primary diagnosis, surgical procedure performed, ensuring that any associated modifiers are also captured. 2 Comprehensive From the clinical note, determine the ICD-10-CM code for acute bronchitis without any complications. 3 Token Limits Be aware of and adhere to length limits, measured in tokens.

5. Choose Words Carefully Precision Choose words precisely and unambiguously to create accurate NLP and AI models. Example Prompt : "From the clinical note, determine the ICD-10-CM code for acute bronchitis without any complications." Apply ICD-10-CM official coding conventions, AHA coding clinic updates.

6. Pose Open-Ended Questions 1 Flexibility Pose open-ended questions to encourage detailed and flexible responses from NLP and AI models. Example Prompt : "Review this outpatient visit transcript and describe any potential diagnoses and their corresponding ICD-10-CM codes."

7. Provide Context for AI Responses Contextual Given this is a pediatric patient's chart, identify the primary diagnosis and provide its specific ICD-10-CM code for pediatric conditions.

8. Set Length Goals for Responses Length Briefly summarize the main findings in this medical record and assign relevant CPT and ICD-10-CM codes.

9. Use Positive Language 1 Avoiding Ambiguity Correctly identify the CPT codes and applicable modifiers for the surgical procedure documented in this operative report. Apply NCCI Guidelines

10. Use Punctuation Strategically Structured Analyze this medical record, focusing on: Chief complaint Procedures performed Medications prescribed MEAT Rule (Managed, Evaluated, Assessed, Treated) Then, provide corresponding ICD-10-CM and CPT codes with applicable modifiers.

11. Encourage Detailed Responses from AI Reviewing Patient Transcripts Review this outpatient visit transcript and describe any potential diagnoses and their corresponding ICD-10-CM codes.

12. Use Precise Language for Detailed Prompts Precision Extract the specific procedure related to the administration of the influenza vaccine in this pediatric record and provide the corresponding CPT code.

13. Avoid Ambiguity and Confusion Clear, Detailed Instructions From this surgical note, identify and provide the exact CPT code for the primary surgical procedure performed, ensuring that any associated modifiers are also captured.