Dashboard

Origination

Clario - AI Agent for Medical Coding v1.1

Patient Information
- Patient Name: Conner Tidd  
- Age/Gender: 26-year-old Male  
- Date of Service: June 2, 2025  
- Provider: Maggie Schauer  
- Specialty: 394800008  
- Place of Service: Office (11)  
- Visit Type: New Patient  
- Telehealth: No

Chief Complaint
Patient presents as a new patient seeking closer psychiatric medication management due to unsatisfactory results from his general practitioner’s management. He reports long wait times for appointments (approximately two months) and recent issues with medication adjustments.

History of Present Illness (HPI)
- Onset & Duration:  
  - PTSD diagnosed approximately 2.5–3 years ago following traumatic events during Marine Corps basic training at age 19.  
  - Depression symptoms noted since age 17–18 with a recent significant depressive episode occurring about 2 months ago before going on medical leave.  
  - Agoraphobia and generalized anxiety have been ongoing, with fluctuations in severity.

- Location:  
  - Trauma during basic training, with current symptoms manifesting in various settings; increased anxiety particularly when leaving home or driving.

- Character & Severity:  
  - PTSD:  
    - Symptoms include auditory and visual hallucinations (stress-induced), flashbacks, hypervigilance in public, irritability, anger outbursts (with dissociative “leaving body” sensation), intrusive memories, emotional numbing, and short-term memory difficulties.  
    - Hallucinations: Auditory (hearing his wife’s voice when she is not present) and visual (shadow figures, peripheral full figures) primarily related to high stress.  
  - Depression:  
    - Presents with nighttime feelings of worthlessness, difficulty experiencing positive emotions, and variable appetite.  
  - Agoraphobia & Anxiety:  
    - Significant anxiety when leaving the house and during driving.  
    - History of panic attacks (currently absent).
  - Sleep Issues:  
    - Maintains a strict sleep regimen; deviations may lead to near-insomnia episodes.
  - Self-harm/Suicidal Ideation:  
    - Past suicidal ideation at age 19 and history of cutting (remitted for 4 years).  
    - Intrusive thoughts of self-harm are present, but without intent, plan, or desire.

- Aggravating/Relieving Factors:  
  - Stress exacerbates PTSD symptoms (especially hallucinations).  
  - Being at home and on medical leave is associated with improved symptom control.  
  - Weekly therapy and coping strategies help mitigate anxiety and agoraphobia.

- Narrative Summary:  
  The patient’s PTSD began with traumatic experiences during Marine Corps basic training, where he faced extreme stress including threats to his safety. This followed into a chronic course of depression and anxiety that have been managed variably over time with medications and psychotherapy. Recently, a medication trial with Paxil while on a higher dose of Wellbutrin resulted in adverse effects. He remains on a stable regimen of Bupropion and utilizes adjunctive medications for mood stabilization and symptom control, though he feels current medications are not adequately targeting PTSD-specific symptoms.

Past Medical History (PMH)
- Psychiatric:  
  - Post-Traumatic Stress Disorder (PTSD)  
  - Major Depressive Disorder  
  - Agoraphobia  
  - Generalized Anxiety  
  - History of Panic Attacks  
  - History of self-harm (cutting, in remission for 4 years)  
  - History of possible hypomanic episodes prior to initiation of current medications (episodes lasted 1–2 days, not seen since medication management)

- Neurological:  
  - Two seizures approximately 5–6 months ago during periods of high stress (non-epileptic in description, lasted 2–3 minutes)

- Medical:  
  - No chronic medical conditions, head trauma, or surgeries

- Medication Reactions:  
  - Adverse reaction to Paxil when reinitiated with Wellbutrin 300mg regimen (hyperactivity, teeth grinding, inability to pay attention, constant “drunk feeling” lasting approx. 3 days)

- Allergies:  
  - No known drug allergies

- Current Non-Psychiatric Medications:  
  - None

- Family History:  
  - Mother: History of depression  
  - Both parents: History of alcoholism

- Social History:  
  - Lives in an apartment in Milwaukee with his wife and three cats (Noodle, Meatball, Tater Tot)  
  - Employed as an Operations Supervisor at FedEx (currently on medical leave for 2.5 months)  
  - Married for 2 years; reports a supportive relationship with his wife  
  - Uses marijuana to help with sleep, minimal alcohol (approximately one beer per week), one caffeinated drink per day, denies tobacco/nicotine  
  - Religion: Jewish  
  - Denies legal issues beyond minor speeding tickets  
  - Good support system including his wife and weekly therapy with Hannah

Review of Systems (ROS)
- General: No weight loss or fever reported  
- Psychiatric:  
  - Mood disturbances (depression, irritability, anxiety)  
  - PTSD symptoms including hallucinations, flashbacks, intrusive memories, emotional numbing  
  - Suicidal ideation not present currently, though past ideation and self-harm behavior noted  
- Neurological:  
  - History of seizures; short-term memory issues noted  
- Sleep:  
  - Strict sleep regimen maintained; occasional near-insomnia if regimen disrupted  
- Cardiovascular, Respiratory, Gastrointestinal, Musculoskeletal, etc.: Not specifically discussed

Physical Examination
- Appearance: Patient attended in-person, not formally documented  
- Behavior: Cooperative, engaged, and open in discussion  
- Speech: Normal rate and rhythm  
- Mood/Affect:  
  - Mood not explicitly stated; patient reports feeling in a “better spot”  
  - Affect appropriate to discussion  
- Thought Process: Linear and goal-directed  
- Thought Content:  
  - Reports intrusive thoughts of self-harm (without intent, plan, or desire)  
  - No suicidal or homicidal ideation  
- Perceptions:  
  - History of auditory and visual hallucinations during high stress; not currently active  
- Cognition:  
  - Alert and oriented; reports short-term memory difficulties  
- Insight & Judgment:  
  - Both good; patient demonstrates understanding of his conditions and treatment needs  
- Vital Signs:  
  - Not documented

Assessment / Diagnosis
1. Post-Traumatic Stress Disorder (PTSD):  
   - Diagnosis supported by history of trauma during Marine Corps training, accompanied by hallmark symptoms (hallucinations under stress, flashbacks, hypervigilance, irritability, intrusive memories, and memory issues). Current low-stress environment on medical leave offers partial control; however, high-stress conditions exacerbate symptoms.

2. Major Depressive Disorder:  
   - Chronic with onset in late adolescence. Residual symptoms include nighttime worthlessness, anhedonia, and variable appetite, with improvement noted on current medication regimen.

3. Agoraphobia:  
   - Ongoing anxiety when leaving home or driving; improved with therapy and coping skills.

4. Generalized Anxiety Disorder:  
   - Persistent anxiety that is less pronounced at home, with a history of intermittent panic attacks.

5. History of Self-Harm (Cutting):  
   - Remitted for 4 years; current intrusive thoughts are present without intent.

6. History of Possible Hypomanic Episodes:  
   - Prior to initiation of medications, episodes of elevated mood and reduced sleep were noted without significant functional impairment; no recent episodes.

7. History of Seizures:  
   - Occurred 5–6 months ago during high stress; requires monitoring given current medication (Bupropion 300mg) that may lower the seizure threshold.

Plan / Treatment
1. Medication Adjustments:  
   - Discontinue Lurasidone (Latuda) 40mg: Initiate a cross-taper schedule.  
   - Initiate Brexpiprazole (Rexulti):  
     - Recently FDA-approved for adjunctive treatment of PTSD.  
     - Starter sample pack provided: 7 tablets of 0.5mg and 7 tablets of 1mg.  
     - Titration Schedule:  
       - Week 1: Latuda 20mg (half tablet) + Rexulti 0.5mg at night  
       - Week 2: Latuda 20mg + Rexulti 1mg at night  
       - Week 3: Discontinue Latuda, start Rexulti 2mg at night (two 1mg tablets)  
     - Provided copay card for pharmacy use.  
     - Patient advised to take with a small snack to mitigate nausea, and to be aware of potential sedation, akathisia, or activation side effects.
   - Continue Bupropion (Wellbutrin) 300mg daily:  
     - Monitor for seizure activity given the patient’s recent history.
   - Continue Prazosin 1mg (up to 3mg as needed) for nightmares:  
     - Use as needed based on symptom occurrence.
   - Continue Hydroxyzine 25mg as needed for anxiety:  
     - Typically utilized for sedation at night or prior to outings where anxiety is anticipated.

2. Therapy and Follow-Up:  
   - Continue weekly talk therapy with Hannah (Ascension) and remain on the waitlist for EMDR.
   - Follow-Up Appointment:  
     - Scheduled for Monday, July 14, 2025 at 9:30 AM.
   - Interim Check-In:  
     - Provider will contact the patient via text around June 18 to assess medication tolerability before sending the full prescription.

3. Pharmacy:  
   - Genoa Pharmacy

4. Patient Education & Safety:  
   - Educated on the titration schedule and potential side effects of Rexulti.  
   - Provided written instructions and a copay card.  
   - Instructed to contact the provider via text (reply to appointment reminder) if any side effects or concerns arise.  
   - Patient denies current suicidal or homicidal ideations and reports feeling safe at home with a supportive network.

Additional Documentation
- Informed Consent:  
  - Patient has been informed of the changes in medication regimen and potential side effects.
- Risk Assessment:  
  - Patient denies current suicidal ideation, plan, or intent. Intrusive thoughts of self-harm are acknowledged without associated risk.
- Signature/Date:  
  - Provider: Maggie Schauer  
  - Date: June 2, 2025

Quality Grade and Feedback
- Quality Grade: A  
- Questions for Improvement:  
  - Are additional details needed regarding the patient’s physical examination (e.g., vital signs) at future appointments?  
  - Would a more detailed breakdown of the titration schedule or specific follow-up parameters be helpful for continued monitoring?  
  - Is there any additional documentation or areas of clarification required for ongoing risk assessments or informed consent procedures?

If you have any further questions or need additional modifications, please let me know!

Formatting

★★★★★4/5

The clinical notes are very comprehensive with detailed history, symptom description, assessment, diagnosis, and a well-outlined treatment plan including medication titration, follow-up scheduling, and risk assessment. However, there are some areas that could benefit from additional detail - particularly the physical exam, such as the documentation of vital signs, which is essential for complete coding and billing purposes.

Queries

Could you please provide the patient's vital signs (e.g., blood pressure, heart rate, respiratory rate, temperature) from the visit? This would help in affirming the physical exam details for accurate coding [e.g., CPT codes for office visits].

Would you be able to include any additional details on the physical examination and any objective findings beyond the general appearance and behavior? Additional documentation on these elements helps ensure complete records for claims processing [e.g., physical exam modifier codes].

The clinical note includes several past conditions (history of self-harm, possible hypomanic episodes, and seizures) that are mentioned in the past medical history. Could you please confirm if you would like these past conditions to be coded as active diagnoses for this visit, or should we only include the active/current psychiatric conditions (PTSD, Major Depressive Disorder, Agoraphobia, and Generalized Anxiety Disorder) that are directly being managed in this encounter? (For example, ICD codes like [F43.10] for PTSD and [90792] for the medication management evaluation.)

Primary Diagnosis

95% Confidence

F43.10 ICD-10-CM i

The primary diagnosis for this visit is Post-Traumatic Stress Disorder. This diagnosis is identified based on the chief complaint and HPI with documented PTSD symptoms including flashbacks, hypervigilance, intrusive memories and stress-induced hallucinations. The code F43.10 is used for PTSD when no further specifier is provided.

Other Diagnosis

90% Confidence

F40.00 ICD-10-CM i

Agoraphobia is present as the patient experiences significant anxiety when leaving home or driving. The code F40.00 corresponds to agoraphobia without panic disorder.

90% Confidence

F33.1 ICD-10-CM i

Major Depressive Disorder, recurrent, moderate is included as the patient has a documented history of persistent depressive symptoms since adolescence with a recent significant depressive episode, which continues to impact his mood. The code F33.1 is used to capture a moderate recurrent depression.

90% Confidence

F41.1 ICD-10-CM i

Generalized Anxiety Disorder is included due to the patient's ongoing symptoms of anxiety that are noted in his history and assessment. The ICD code F41.1 is used to define generalized anxiety disorder.

Procedures

95% Confidence

90792 CPT i

The procedure performed in this visit is a comprehensive psychiatric diagnostic evaluation with medication management, which is appropriately coded with 90792. The documentation of medication adjustments and management changes supports this code usage.

Performed By Maggie Schauer
Modifier Value

Performed On June 2, 2025
Units Or Days

Schedule Unknown

Reason New patient evaluation for psychiatric medication management.

Payer Rules Evaluation

The reported procedure code (90792) is used for a psychiatric diagnostic evaluation with medical decision making and does not fall under the payer’s coverage criteria, which exclusively address endovenous ablation and ultrasound‐guided foam sclerotherapy for symptomatic lower‐extremity CVI/varicose veins. The listed ICD‑10‑CM codes (F43.10, F33.1, F40.00, F41.1) describe psychiatric conditions and have no relevance to the vascular criteria outlined. In other words, the mapping of 90792 to a diagnosis is not applicable under the payer’s rules for varicose vein interventions. The rules require specific documentation of symptoms, duplex imaging findings, CEAP classification, and a history of conservative therapy for CVI, none of which are present. Additionally, prior authorization, specific modifiers, and documentation requirements are mandated only for the related vascular procedures. Since the payer rules are silent on mental health evaluations, this pairing is not addressed by the criteria provided. This discrepancy requires clarification to ensure that the correct procedure is being pursued. (Needs Clarification)