Automating ICD-10 coding from discharge summaries remains demanding because coders analyze clinical narratives while justifying decisions. This study compares three automation patterns: PLM-ICD as a standalone deep learning system emitting 15 codes per case, LLM-only generation with full autonomy, and a hybrid approach where PLM-ICD drafts candidates for an agentic LLM audit to accept or reject. All strategies were evaluated on 19,801 MIMIC-IV summaries using four LLMs spanning compact (Qwen2.5-3B-Instruct, Llama-3.2-3B-Instruct, Phi-4-mini-instruct) to large-scale (Sonnet-4.5). Precision guided evaluation because coders still supply any missing diagnoses. PLM-ICD alone reached 55.8% precision while always surfacing 15 suggestions. LLM-only generation lagged severely (1.5–34.6% precision) and produced inconsistent output sizes. The agentic audit delivered the best trade-off: compact LLMs reviewed the 15 candidates, discarded weak evidence, and returned 2–8 high-confidence codes. Llama-3.2-3B-Instruct, for example, improved from 1.5% as a generator to 55.1% as a verifier while trimming false positives by 73%. These results show that positioning LLMs as quality controllers, rather than primary generators, yields reliable support for clinical coding teams, while formal recall/F1 reporting remains future work for fully autonomous implementations.
Akkhawatthanakun et al. (Wed,) studied this question.