Refining a Diagnosis

Refine offers more specific versions of a diagnosis, each with the codes it would use and the reason it fits based on your note. Nothing changes until you select Adjust.

A diagnosis stated in conversation is usually less specific than the one that belongs on the claim. “Anemia” is what gets said; anemia due to stage 3b chronic kidney disease is what the visit actually documented. Refine closes that gap for you, and shows its reasoning so you can judge it.

Why refinement is offered

Two things happen when a diagnosis is coded more precisely than the conversation stated it. The claim describes the encounter accurately, and you did not spend the time searching for the code that does it. Refinement is where Scribe does that work and hands you the decision.

Scribe builds each suggestion from what is already in the visit: the transcript, the note, and the patient’s documented history. It does not invent a more specific condition to reach a better code. If the supporting detail is not there, the suggestion is not offered.

Opening the refinements for a diagnosis

On the Diagnoses tab, find a card that shows Refine next to the diagnosis name.

Select Refine. A Possible refinements panel expands beneath the diagnosis.

Select it again, or use the collapse control, to close the panel.

No Refine on a card means Scribe did not find a more specific version the visit supports. That is a normal outcome, not a gap. You can still attach codes yourself with + Add ICD-10.

Reading a refinement

Each suggestion in the panel gives you four things:

Element	What to do with it
The proposed diagnosis	Read it as a clinical statement. Is this what you documented and managed?
The codes it would use	The ICD-10 codes that replace or accompany the current ones, plus any HCC category the coded condition maps to. HCC chips are informational.
Why this fits	Scribe’s reasoning, quoting the note language it relied on. This is the part worth reading closely, because it tells you exactly what the suggestion is standing on.
Adjust	Applies the refinement. Until you select it, nothing on the card changes.

Accepting a refinement

Read the reasoning first, not the code. The codes are only correct if the reasoning holds.

Confirm the note supports it. If the refinement relies on a stage, a cause, or a manifestation, that detail needs to be documented, not just plausible. Use the Transcript tab if you want to see where a detail came from.

Select Adjust. The card updates to the refined diagnosis and its codes.

Check the chips on the card. Confirm the codes that landed are the ones you expected, and add any that are missing with + Add ICD-10.

Update the Assessment and Plan. A refined diagnosis often deserves refined reasoning. Edit the text directly, or tell Scribe what to change in plain language from the Note tab.

Refine, then read the note. Because the Note and Diagnoses tabs describe the same visit, a meaningful refinement is worth a quick look at the corresponding section of the note to be sure the two still agree.

When to decline one

Declining is simply not selecting Adjust. Leave the original diagnosis in place when:

The causal link is not established. Two conditions appearing in the same note does not make one the cause of the other. “Due to” has to be documented.
Staging or severity is not confirmed. If the stage came from older data you have not verified this visit, or was estimated in conversation, the unspecified code is the honest one.
You did not manage that condition. Refining toward a condition you referred out rather than addressed changes what the encounter claims to be.
The suggestion reads as a better code rather than a better description. Specificity should follow the documentation, never the other way around.

A thumbs-down flags a suggestion that missed, which tells the Scribe team where the refinements need work.

Adjusting codes yourself

You are not limited to what Scribe suggests:

+ Add ICD-10 on any card attaches an additional code you have chosen.
Remove a code that does not belong on the diagnosis.
Remove the whole diagnosis with the card’s remove action if the condition was discussed but not addressed.
Add a diagnosis Scribe missed from the search field at the top of the tab. See Diagnoses in EverHealth Scribe.

Frequently asked questions

Will a refinement change my diagnosis automatically?

No. Nothing changes until you select Adjust.

Why is a refinement suggesting a link between two conditions?

Because it found language in the note connecting them. The suggestion quotes what it relied on so you can judge whether the documentation truly establishes that relationship. If it does not, do not select Adjust. A causal code needs a documented cause.

Can I undo a refinement after applying it?

Edit the card directly: remove the codes that no longer apply and attach the ones you want with + Add ICD-10. You can also correct the diagnosis in OfficeEMR before you sign off.

I dismissed the “Draft suggestions only” message. Did that change anything?

Only the banner. Refinements still wait on Adjust, and you remain responsible for reviewing every diagnosis and code before signing.

Should I always take the most specific option?

No. Take the most specific option your documentation supports. If the note does not establish the stage, the cause, or the manifestation, the less specific code is the correct one.