Automatic Medical Coding (AMC), which assigns standardized International Classification of Diseases (ICD) codes to clinical notes, is essential for medical reimbursement, quality reporting, and clinical research. Existing pre-trained language model (PLM)-based methods typically formulate AMC as an extreme multi-label classification problem over a predefined code set, while recent large language model (LLM)-based approaches instead frame it as generation or multi-step reasoning. However, key challenges remain, including the extreme length of clinical notes that hinders effective interpretation, the vast ICD label space, and complex coding rules that are not explicitly captured by LLMs. In this work, we propose Knowledge-Guided Reasoning over Clinical Evidence with LLMs (KREL), a framework that leverages LLMs for clinical text understanding and reasoning while integrating selected structured coding relations as external knowledge. This design enables tight coupling between domain knowledge and LLM reasoning, reducing hallucinations and supporting rule-aware verification. Experiments on benchmark datasets show that KREL consistently outperforms strong PLM-based and state-of-the-art LLM-based baselines.

Large Reasoning Models (LRMs) achieve strong performance on complex tasks through extended chains of thought but suffer from high inference latency due to autoregressive reasoning. Recent work explores using Small Reasoning Models (SRMs) to accelerate LRM inference, yet existing frameworks such as SpecReason adopt a polling-based design that repeatedly invokes the LRM for verification at every step. This approach is inefficient, as frequent LRM calls introduce a high computational overhead, and is unreliable, since the LRM as a judge is prone to errors. In this paper, we systematically characterize the capability boundaries of SRMs and identify three common types of reasoning risks: (1) path divergence, where SRMs lack the strategic ability to construct an initial plan, causing reasoning to deviate from the most probable path; (2) cognitive overload, where SRMs fail to solve particularly difficult steps; and (3) recovery inability, where SRMs lack robust self-reflection and error correction mechanisms. To address these challenges, we propose TrigReason, a trigger-based collaborative reasoning framework that replaces continuous polling with selective intervention. TrigReason delegates most reasoning to the SRM and activates LRM intervention only when necessary—during initial strategic planning (strategic priming trigger), upon detecting extraordinary overconfidence (cognitive offload trigger), or when reasoning falls into unproductive loops (intervention request trigger). The evaluation results on AIME24, AIME25, and GPQA-D indicate that TrigReason matches the accuracy of full LRMs and SpecReason, while offloading 1.70×–4.79× more reasoning steps to SRMs. Under edge–cloud conditions, TrigReason reduces latency by 43.9% and API cost by 73.3% compared to SpecReason.