Challenges and Solutions in Applying Large Language Models to Guideline-Based Management Planning and Automated Medical Coding in Health Care: Algorithm Development and Validation.

Abstract

Background: Diagnostic errors and administrative burdens, including medical coding, remain major challenges in health care. Large language models (LLMs) have the potential to alleviate these problems, but their adoption has been limited by concerns regarding reliability, transparency, and clinical safety.

Objective: This study introduces and evaluates 2 LLM-based frameworks, implemented within the Rhazes Clinician platform, designed to address these challenges: generation-assisted retrieval-augmented generation (GARAG) for automated evidence-based treatment planning and generation-assisted vector search (GAVS) for automated medical coding.

Methods: GARAG was evaluated on 21 clinical test cases created by medically qualified authors. Each case was executed 3 times independently, and outputs were assessed using 4 criteria: correctness of references, absence of duplication, adherence to formatting, and clinical appropriateness of the generated management plan. GAVS was evaluated on 958 randomly selected admissions from the Medical Information Mart for Intensive Care (MIMIC)-IV database, in which billed International Classification of Diseases, Tenth Revision (ICD-10) codes served as the ground truth. Two approaches were compared: a direct GPT-4.1 baseline prompted to predict ICD-10 codes without constraints and GAVS, in which GPT-4.1 generated diagnostic entities that were each mapped onto the top 10 matching ICD-10 codes through vector search.

Results: Across the 63 outputs, 62 (98.4%) satisfied all evaluation criteria, with the only exception being a minor ordering inconsistency in one repetition of case 14. For GAVS, the 958 admissions contained 8576 assigned ICD-10 subcategory codes (1610 unique). The vanilla LLM produced 131,329 candidate codes, whereas GAVS produced 136,920. At the subcategory level, the vanilla LLM achieved 17.95% average recall (15.86% weighted), while GAVS achieved 20.63% (18.62% weighted), a statistically significant improvement (P<.001). At the category level, performance converged (32.60% vs 32.58% average weighted recall; P=.99).

Conclusions: GARAG demonstrated a workflow that grounds management plans in diagnosis-specific, peer-reviewed guideline evidence, preserving fine-grained clinical detail during retrieval. GAVS significantly improved fine-grained diagnostic coding recall compared with a direct LLM baseline. Together, these frameworks illustrate how LLM-based methods can enhance clinical decision support and medical coding. Both were subsequently integrated into Rhazes Clinician, a clinician-facing web application that orchestrates LLM agents to call specialized tools, providing a single interface for physician use. Further independent validation and large-scale studies are required to confirm generalizability and assess their impact on patient outcomes.