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Patient Information
- Patient Name: Anni Larson  
- Date of Birth: 12/19/1995  
- Date of Service: 10/06/2025  
- Provider: Molly Jahrling  
- Provider Specialty Code: 394800008  
- Place of Service: Office (11)  
- Visit Type: New Patient  
- Telehealth: No

Chief Complaint
Patient presents for the establishment of psychiatric care in Illinois after relocating from New York for graduate school. She is seeking medication management for ADHD and wishes to continue her current medication regimen previously managed by her New York-based psychiatrist.

History of Present Illness (HPI)
Narrative:  
Ms. Larson is a 29-year-old female with a long-standing history of ADHD, predominantly inattentive type, and depression. She was first diagnosed with ADHD around 2015, with symptoms beginning in childhood (difficulty sitting still, distractibility, impulsivity) and confirmed by prior neuropsychological testing. Her current symptoms include difficulty initiating tasks, organizational challenges, and distractibility. She has developed positive study habits after starting medication in late adolescence and is presently stable on Vyvanse, although she experiences some restlessness and dry mouth on higher doses.  
She also has a history of depression, diagnosed approximately 2015–2016, characterized by brief episodes (around twice yearly, lasting about 3 days) with increased tearfulness and emotional lability, typically related to menstrual cycle timing and seasonal variations. Additionally, she experiences significant premenstrual symptoms that include irritability and physical pain (notably intense cramping for at least one week monthly). Sleep disturbances occur intermittently, particularly about one week prior to her menstrual period, and she uses trazodone as needed.

HPI Details:  
- Onset:  
  - ADHD: Detected in childhood; formal diagnosis ~2015  
  - Depression: Began around 2015–2016  
- Location: Not applicable  
- Duration:  
  - ADHD: Chronic, managed over years  
  - Depressive episodes: Approximately 3 days per episode, occurring twice yearly  
- Character:  
  - ADHD: Inattentive symptoms, distractibility, difficulty with task initiation  
  - Depression: Periodic tearfulness and mood lability; premenstrual pain and irritability  
- Aggravating/Relieving Factors:  
  - ADHD: Higher Vyvanse doses may lead to restlessness/dry mouth; improved symptoms with current regimen  
  - Depression/Premenstrual: Symptoms worsen with hormonal changes and in winter months (less sunlight/outdoor activity)  
- Timing:  
  - ADHD: Daily, correlated with work schedule (medication taken around 9–9:30 AM, work until 8 PM)  
  - Depressive and premenstrual symptoms: Occur seasonally or during menstrual cycle stages  
- Severity:  
  - ADHD: Managed with current stimulant regimen with occasional side effects  
  - Depression/Premenstrual: Mild to moderate episodes not requiring antidepressant medication at this time  
- Narrative Summary:  
  The patient is transferring care to manage her chronic ADHD and recurrent depressive symptoms. She remains functionally stable and is currently on an established medication regimen. Her sleep interruptions coincide with both hormonal cycles and occasional work-related stress, secondary in part to vivid dreams on trazodone.

Past Medical History (PMH)
- Psychiatric:  
  - Attention-Deficit/Hyperactivity Disorder, predominantly inattentive type (diagnosed ~2015)  
  - Major Depressive Disorder, recurrent, in partial remission (diagnosed ~2015–2016)  
- Medical:  
  - Exercise-induced asthma (childhood)  
  - Gastroesophageal reflux disease (GERD) – on medication (noted as lamotrigine in records, likely intended to be a different agent)  
  - Seasonal allergies  
  - Allergy to cats (symptoms: itchy nose and throat)  
- Surgical:  
  - Tonsillectomy

Review of Systems (ROS)
- Psychiatric:  
  - Mood: "Up and down," stable; experiences mild depressive episodes twice a year  
  - Energy/Motivation: Good  
  - Suicidal/Homicidal Ideation: Denies both current and past  
  - Anxiety: Denies significant anxiety; negative response to prior SSRI trials  
  - Sleep: Occasional disturbances, with middle-of-the-night awakenings and vivid dreams  
  - Psychotic Symptoms: Denies auditory or visual hallucinations  
- General:  
  - Appetite: Good; maintains regular meal pattern  
  - Menstrual: Chronic cramping and premenstrual mood changes noted  
- Other Systems: No additional significant symptoms reported

Physical Examination
- Vital Signs:  
  - To be obtained during in-office visit (pending)  
- General Appearance:  
  - Patient is cooperative and engaged; attended in-person  
- Mental Status:  
  - Appearance: Not formally documented  
  - Behavior: Cooperative, engaged  
  - Speech: Normal rate, rhythm, and volume; coherent and goal-directed  
  - Mood: Described by patient as "up and down"  
  - Affect: Appropriate, exhibiting a full range  
  - Thought Process: Linear, logical, organized  
  - Thought Content: No suicidal, homicidal, or obsessive/ruminative thoughts  
  - Perceptions: Denies auditory or visual hallucinations  
  - Cognition: Alert and oriented; intact attention  
  - Insight & Judgment: Good; understands her conditions and treatment decisions

Assessment / Diagnosis
1. Attention-Deficit/Hyperactivity Disorder, Predominantly Inattentive Presentation  
   - Clinical Reasoning:  
     - Early diagnosis confirmed by neuropsychological testing  
     - Managed with Vyvanse; patient reports difficulties with task initiation and distractibility  
     - Some dose-related side effects (restlessness, dry mouth) noted on higher doses

2. Major Depressive Disorder, Recurrent, in Partial Remission  
   - Clinical Reasoning:  
     - History of episodic depressive symptoms occurring twice yearly  
     - Previous antidepressant trials (Lexapro and Prozac) were ineffective and poorly tolerated  
     - Current depressive symptoms are mild and correlate with seasonal changes and menstrual cycle

3. Seasonal Pattern (Specifier)  
   - Clinical Reasoning:  
     - Patient experiences worsening mood during winter months due to less sunlight and outdoor activity

4. Premenstrual Symptoms  
   - Clinical Reasoning:  
     - Significant chronic cramping and mood changes associated with menopausal cycle  
     - Utilizing a copper IUD with ongoing issues; potential for OB/GYN follow-up regarding hormonal treatment

5. Insomnia, Intermittent  
   - Clinical Reasoning:  
     - Sleep disturbances occur in relation to menstrual cycle and stress  
     - Managed with PRN trazodone

Plan / Treatment
 Medication Management
1. Vyvanse (lisdexamfetamine) 20mg:  
   - Instruction: Take one capsule by mouth daily in the morning  
   - Note: Changed from an alternating 20mg/30mg regimen to a consistent 20mg dose  
   - Dispense: 30-day supply  
   - Pharmacy: Jewel-Osco on Southport (60614)

2. Methylphenidate 5mg tablets:  
   - Instruction: Take one tablet by mouth as needed in the afternoon (no later than 1–2 PM)  
   - Plan: NEW trial for 2 weeks; may increase to 10mg if necessary  
   - Dispense: 10–14 tablets for the trial period  
   - Alternative Option: Consider switching dosing times (morning methylphenidate and later Vyvanse) if preferred

3. Trazodone 25–50mg:  
   - Instruction: Take at bedtime as needed for sleep  
   - Continued use noted; discuss potential for vivid dreams

4. Lorazepam (Ativan) 0.5mg:  
   - Instruction: Take as needed (infrequent use)

5. Supplements:  
   - Continue Magnesium glycinate, Vitamin B complex, Vitamin C, and Vitamin D (especially during winter months)

Non-Pharmacological Recommendations
- Diet and Exercise:  
  - Continue daily exercise (walking, gym routines)  
  - Discussed Mediterranean diet and potential benefits of anti-inflammatory/ketogenic nutrition; resources to be provided

- ADHD Support:  
  - Recommended resource: ADDitude Magazine website (additudemag.com) for organizational tips and management strategies

- Seasonal Depression Management:  
  - Light box therapy recommended (10,000 lux for 20 minutes in the morning)  
  - Encourage outdoor morning sunlight when feasible

- Therapy:  
  - Continue weekly therapy sessions with Brooke Allen at Live Oak  
  - Provider offered to participate in care coordination with her therapist if needed (release of information can be arranged)

Patient Education
- Discussion regarding potential trazodone effects on sleep architecture (vivid dreams)  
- Review of various treatment options for PMDD, with consideration of past adverse reactions to SSRIs  
- Explanation of differences between stimulant medications and rationale for addition of methylphenidate

Coordination of Care
- Previous Psychiatrist: Dr. Patricia Levy (New York) – continued monitoring as needed (1–2 times per year)  
- Current Therapist: Brooke Allen at Live Oak (weekly sessions)  
- Emphasis on avoiding multiple prescribers for the same medications to prevent conflicting recommendations

Safety and Follow-Up
- Safety:  
  - No current safety concerns; patient denies suicidal/homicidal ideation  
  - Patient feels safe at home, lives alone with her dog, and has no weapons at home

- Follow-Up Appointment:  
  - Scheduled for Thursday, November 6, 2025 at 10:00 AM (virtual)  
  - Plan for follow-up in approximately 4 weeks to review medication changes  
  - Ongoing care: Seen at least every 3 months for stimulant prescriptions (virtual visits acceptable unless vital signs or safety concerns necessitate an in-person encounter)

- Communication:  
  - Provider card provided with contact details  
  - Patient instructed to email or call with feedback on the methylphenidate trial or any medication adjustments  
  - Medication refill requests to be made timely; if no response within 2–3 days, the patient should resend the message

Prescriptions Sent
1. Vyvanse 20mg 30:  
   - Sent to Jewel-Osco on Southport; generic substitution permitted
2. Trazodone:  
   - Pending (due to technical difficulty at time of visit)
3. Methylphenidate 5mg:  
   - Pending (due to technical difficulty at time of visit)

Additional Documentation
- Informed Consent:  
  - Discussed risks and benefits of treatment changes; patient provided verbal consent for management plan and medication adjustments.
- Risk Assessment:  
  - No current suicidal or homicidal ideation; safety screening completed.
- Provider Signature:  
  - Molly Jahrling  
- Date:  
  - 10/06/2025

Quality Grade: A

Questions for Improvement:
- Would additional detail regarding exact vital signs at the time of visit (once available) further benefit the physical examination section?
- Is there a need to further elaborate on specific non-pharmacological interventions or scheduling a follow-up for revisiting menstrual-related symptom management with OB/GYN?

Please advise if any further modifications are needed.

Formatting

★★★★★5/5

The clinical note is exceptionally detailed and organized. It includes comprehensive patient demographics, a well-described HPI with relevant details (onset, duration, character, timing, and severity), complete past medical history, a thorough Review of Systems, a physical exam with documentation of mental status, detailed assessments with clinical reasoning, and a clear, itemized plan including medication management and non-pharmacological recommendations. These elements are crucial for accurate coding, billing, and claims processing.

Queries

Could you please provide the specific vital signs obtained during the in-office visit (e.g., blood pressure, heart rate, temperature)? These details would be valuable to accurately document the physical exam portion (potentially affecting E/M coding such as CPT 90792).

There appears to be an inconsistency in the Past Medical History regarding the treatment of GERD. The notes mention lamotrigine, which is not typically used for GERD. Could you please clarify the correct medication or details for GERD management? (Clarification is needed to ensure accurate documentation for medication-related coding.)

Could you please confirm if the vital signs were eventually obtained or document them fully? (This is important for coding evaluation of the physical examination, e.g., CPT codes for office visits.)

For the premenstrual symptoms noted, would you like to document a coordinated follow‐up with OB/GYN or include additional details regarding the severity and management of these symptoms? This clarification may impact the selection and specificity of the diagnosis codes such as N94.3.

Primary Diagnosis

95% Confidence

F90.0 ICD-10-CM i

Attention-Deficit/Hyperactivity Disorder, predominantly inattentive presentation is documented as the chief complaint for establishing psychiatric care, with symptoms of distractibility and difficulty initiating tasks. ICD-10 code F90.0 is chosen for this presentation.

Other Diagnosis

90% Confidence

G47.00 ICD-10-CM i

Intermittent insomnia, characterized by sleep disturbances (including middle-of-the-night awakenings and vivid dreams) is documented and managed with trazodone. G47.00 is used as an unspecified insomnia code.

90% Confidence

F33.41 ICD-10-CM i

Major Depressive Disorder, recurrent, in partial remission is documented with episodic depressive symptoms that occur approximately twice yearly. Code F33.41 is selected to represent this state, acknowledging the mild to moderate episodes described.

90% Confidence

N94.3 ICD-10-CM i

Premenstrual symptoms with significant cramping and mood changes are noted in the history. ICD-10 code N94.3 is used to capture premenstrual tension syndrome.

Procedures

95% Confidence

90792 CPT i

The patient’s visit involves the establishment of psychiatric care with medication management. Since it is a new patient evaluation with medical services provided (including detailed history and medication review), CPT 90792 is the most appropriate code.

Performed By Molly Jahrling
Modifier Value

Performed On 10/06/2025
Units Or Days

Schedule Unknown

Reason New patient establishment of care for psychiatric medication management.

Payer Rules Evaluation

The provided procedure code 90792, which represents a psychiatric diagnostic evaluation with medical services, does not map to any of the covered diagnosis or procedure codes outlined in the payer rules for endovenous ablation or foam sclerotherapy for lower-extremity chronic venous insufficiency. The associated diagnosis codes (F90.0, F33.41, N94.3, G47.00) pertain to psychiatric and menstrual-related conditions rather than venous disease. The payer rules require documentation of symptomatic lower-extremity CVI, duplex scan findings, CEAP classification, and a minimum six-week course of conservative therapy for the procedures described. None of these criteria are applicable or documented here. Additionally, prior authorization and specific documentation requirements for the varicose vein treatments are not provided since the service and clinical presentation are different. This discrepancy indicates that the current claim does not comply with the payer rules for varicose vein ablation procedures.