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Clario - AI Agent for Medical Coding v1.1

Below is the reformatted clinical note using the standardized template:

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Patient Information
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• Name: Alessandra Belmonte  
• Age: 26 years old  
• Gender: Female  
• Date of Service: 9/8/2025  
• Provider: Molly Jahrling  
• Place of Service: Office (11)  
• Visit Type: New Patient Evaluation  
• Telehealth: No

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Chief Complaint
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Patient presents as a new patient to establish psychiatric care after relocating from Nashville to Chicago and to address concerns related to her current psychiatric treatment, including medication-induced sexual dysfunction.

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History of Present Illness (HPI)
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• Narrative:  
 – Patient recently relocated back to Chicago from Nashville, having previously been seen at Clarity Clinic in Chicago.  
 – Initially started on lamotrigine in 2013 by her neurologist for chronic migraines; noted significant mood stabilization and improvement of sensitivity and rapid mood shifts.  
 – In 2018, upon discontinuing lamotrigine due to the perception of wellness, experienced worsening migraines, increased anxiety, social withdrawal, and depressive symptoms leading to a subsequent restart of lamotrigine with stabilization.  
 – Experienced postpartum depression after the birth of her daughter (18 months old) with low energy, decreased hygiene, and decreased appetite; treated effectively with sertraline.  
 – Over the past 3–6 months, mood has been good overall with episodic anxiety—particularly around menstrual periods and marital conflicts.  
 – Reports ruminating thoughts (e.g., waking at 2–3 AM with worries about her marriage); anxiety accompanied by muscle tightness and nausea; panic attacks approximately every 3 months; and obsessive thoughts following marital conflicts.

• Onset/Duration:  
 – Mood symptoms and anxiety have been present episodically over the past 3–6 months with historical symptoms dating back to 2013.  
 – Postpartum depression occurred following the birth of her daughter (18 months ago).

• Character:  
 – Mood: “Good” overall with episodes of heightened sensitivity and anxiety.  
 – Anxiety: Ruminative and sometimes accompanied by physical symptoms (muscle tightness, nausea).

• Aggravating/Relieving Factors:  
 – Aggravation: Marital conflicts and relationship stress; sensitivity around menstrual periods.  
 – Relieving: Sleep hygiene measures (avoiding screens, audiobooks); supportive lifestyle factors (exercise, hobbies).

• Associated Concerns:  
 – Medication-induced sexual dysfunction associated with sertraline (loss of sex drive, decreased spontaneous arousal, decreased vaginal lubrication).  
 – Past side effects with lamotrigine (pruritus ani) preventing dose increase.

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Past Medical History (PMH)
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• Chronic migraines with aura (historically more than 15 days/month)  
• Anemia (notably during breastfeeding; improved with iron supplementation)  
• Latex allergy

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Past Psychiatric History
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• Diagnosed Conditions:  
 – Mood disorder  
 – Generalized anxiety  
 – Postpartum depression  
 – ADHD, inattentive type (diagnosed in 6th grade)  
 – Bulimia Nervosa (in remission for approximately 4 years)  
 – History of self-injurious behavior (cutting in 2013)

• Previous Psychiatric Providers:  
 – Clarity Clinic, Chicago  
 – Psychiatrist in Nashville  
 – Dr. Mehta in Chicago  
 – Dr. Mueller (therapist) in Memphis, Tennessee

• Hospitalizations:  
 – No psychiatric hospitalizations; hospitalizations for migraines noted.

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Review of Systems (ROS)
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• General: Stable  
• Neurological: History of chronic migraines  
• Psychiatric:  
 – Mood: Generally “good” with episodic anxiety  
 – Sleep: Currently reports 8–9 hours per night with no significant difficulty (past ruminative thoughts at night)  
 – Appetite: Good with a healthy diet  
 – Sexual: Decreased libido, decreased spontaneous arousal, and vaginal lubrication issues (on sertraline)  
• Other: No current hallucinations, suicidal ideation, or homicidal ideation

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Physical Examination
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• Appearance: Attended in-person; not formally documented  
• Behavior: Cooperative, engaged, talkative, and a good historian  
• Speech: Normal rate and volume, coherent with occasional tangentiality (“word vomiting”)  
• Mood: Reported as “good” with some anxiety  
• Affect: Appropriate, full range, congruent with content  
• Thought Process: Linear, goal-directed, with some circumstantiality  
• Thought Content: No current suicidal or homicidal ideation; persistent obsessive worries about marriage following conflict  
• Perceptions: No hallucinations reported  
• Cognition: Alert, oriented, intact memory and attention  
• Insight/Judgment: Good  
• Vital Signs: Not performed (psychiatric visit)

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Assessment / Diagnosis
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1. Mood Disorder  
 – Stable on lamotrigine ER 100 mg daily. Notable family history of bipolar disorder; however, the patient denies prolonged manic episodes.

2. Generalized Anxiety Disorder  
 – Episodic anxiety with ruminative thoughts and physical symptoms; managed with diazepam PRN.

3. Major Depressive Disorder (currently in remission)  
 – History of postpartum depression effectively treated with sertraline.

4. Medication-Induced Sexual Dysfunction  
 – Decreased libido, spontaneous arousal, and vaginal lubrication on sertraline impacting relationship satisfaction.

5. ADHD, Inattentive Type  
 – Diagnosed in childhood; currently not on active treatment due to previous adverse effects with stimulants.

6. Bulimia Nervosa (in remission)  
 – No current compensatory behaviors; maintained on a healthy eating pattern.

7. History of Self-Injurious Behavior  
 – Past cutting (in 2013) with no recurrence in over 12 years.

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Plan / Treatment
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Medications:  
• Lamotrigine ER 100 mg – Continue one tablet daily. (3 refills; sent to CVS on Broadway)  
• Sertraline 100 mg – Continue daily with a “medication holiday” strategy (skip dose on days planning for sexual activity, not to exceed 2 consecutive days) to assess improvement in sexual side effects; prescription sent to pharmacy.  
• Diazepam 5 mg – Continue PRN for acute anxiety episodes (usage approximately once weekly; quantity: 15 tablets prescribed).

Non-Pharmacological Interventions:  
• Diet and Exercise – Patient engaged in regular physical activities (walking 2+ miles daily, yoga, and planned Pilates) and maintains a healthy diet.  
• Magnesium Glycinate – Continue current supplementation (also included in postnatal vitamins) for anxiety and sleep support.  
• Sleep Hygiene – Continue current strategies (avoiding screens before bed, listening to audiobooks).  
• Morning Sunlight – Continue exposure; light box discussed as an option for seasonal affective concerns.  
• Therapy – Discussed interest in couples therapy; referral to be provided if desired.

Patient Education:  
• Reviewed the safety of current medications during pregnancy/breastfeeding (lamotrigine and sertraline are appropriate; diazepam would require discontinuation if pregnant).  
• Reviewed bipolar disorder screening; patient denies history of manic episodes meeting diagnostic criteria.  
• Discussed medication vacation strategy regarding sertraline to address sexual dysfunction concerns.  
• Advised to consult OB/GYN regarding sexual dysfunction (upcoming OB/GYN appointment on the 18th).

Coordination of Care:  
• Follow-up with OB/GYN regarding sexual dysfunction and treatment options.  
• Notify provider if considering conception to facilitate medication adjustments.  
• Primary care appointment scheduled for April at Northwestern.  
• Migraine management with neurologist Dr. Diamond continues.

Follow-Up:  
• Return to clinic in 6 weeks (October 20, 2025 at 2:30 PM, in-person) to evaluate the response to the medication holiday strategy and any interventions initiated by OB/GYN.  
• Patient instructed to contact the office with any concerns prior to the appointment.

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Additional Documentation
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• Informed Consent: Discussed safety and risks related to medications and treatment plans.  
• Risk Assessment:  
 – Suicide/Homicidal ideation: None currently; history of passive ideation and past cutting, none in recent years.  
 – Safety: Medications stored safely; no weapons in the home.  
• Signature/Date:  
 – Provider: Molly Jahrling  
 – Specialty: Psychiatry (394800008)  
 – Date: 9/8/2025

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Quality Grade & Questions for Improvement
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Quality Grade: A

Additional Questions for Improvement:  
1. Are there additional details required regarding the onset and specific timing of symptom fluctuations that could further clarify the HPI?  
2. Would including more detailed past psychotherapy interventions (e.g., duration and outcomes) improve the historical context?  
3. Is there a need for further documentation on the patient’s social history or occupational impact beyond what was noted to better support the individualized treatment plan?

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All information above has been reformatted from the original clinical notes without the addition of new data.

Formatting

★★★★★5/5

The clinical note is detailed and well-organized, covering all essential components for medical coding, billing, and claims processing. It comprehensively documents patient demographics, history of present illness, past medical and psychiatric history, review of systems, physical exam findings, assessments/diagnoses, and a clear treatment plan with follow-up instructions. The inclusion of medication details and refills, as well as non-pharmacological interventions and coordination of care, makes it very coder-friendly.

Queries

Regarding the Major Depressive Disorder (currently in remission) diagnosis: Could you please confirm if this is a recurrent depressive disorder or a single episode that is now in remission? Clarification on this point will assist in choosing the most precise ICD-10 code (for example, F33.41 for recurrent MDD, in remission). [Reference: MDD coding specifics].

Can you please clarify the exact nature of the 'Mood Disorder' diagnosis? Given the use of lamotrigine (often used in bipolar disorder) and the absence of prolonged manic episodes, is this intended to represent a form of bipolar disorder (and if so, which type) or another mood disorder? This will help ensure the selection of the most specific ICD-10 code (e.g., F31.9 for bipolar disorder, unspecified, or an alternative code). [Reference: Mood Disorder coding considerations].

The provided note only contains placeholder text with no clinical details regarding wound treatment, measurements, or specifics of any procedure performed. Could you please clarify if any wound was actually treated during this encounter? Additionally, was an E&M service provided (e.g., office visit, 99213 or another level) that should be coded? Clarification is required so we may appropriately assign wound-specific procedure codes or confirm that no treatment/billing is applicable.

Could you elaborate on the timeline and specific frequency of migraine episodes and any recent changes in her migraine management? This clarification would help refine coding for chronic migraine management [e.g., G43.709].

Could you provide additional details regarding the patient’s social and occupational history (e.g., work status, living situation, support systems)? This information can impact the overall treatment and is useful for coding related social or economic factors [e.g., Z56, Z60].

Primary Diagnosis

95% Confidence

F52.22 ICD-10-CM i

The primary diagnosis is medication-induced sexual dysfunction as indicated by the patient's report of decreased libido, decreased spontaneous arousal, and vaginal lubrication issues while on sertraline. F52.22 corresponds to female sexual interest/arousal disorder, which is used here to capture the medication-induced sexual side effects affecting her sexual function.

Other Diagnosis

90% Confidence

Z91.5 ICD-10-CM i

History of Self-Injurious Behavior – The patient has a past history of self-injurious behavior (cutting in 2013) with no recurrence in over 12 years. Z91.5 is used to denote a personal history of self-harm.

95% Confidence

F41.1 ICD-10-CM i

Generalized Anxiety Disorder – The diagnosis is supported by her episodic anxiety, ruminative thoughts, and associated physical symptoms such as muscle tightness and nausea, which aligns with F41.1.

90% Confidence

F33.41 ICD-10-CM i

Major Depressive Disorder in remission – The patient has a history of postpartum depression successfully treated with sertraline. Pending confirmation on whether this represents a recurrent episode or a single episode in remission (see Query 2), F33.41 is provisionally used for recurrent MDD in remission.

85% Confidence

F31.9 ICD-10-CM i

Mood Disorder – The patient is stable on lamotrigine. Although she denies prolonged manic episodes, lamotrigine is typically used for bipolar conditions. Pending clarification (see Query 1), F31.9 (Bipolar disorder, unspecified) is provisionally used.

95% Confidence

F90.0 ICD-10-CM i

ADHD, Inattentive Type – Confirmed diagnosis from childhood with a history of adverse effects with stimulant medications, coded as F90.0.

95% Confidence

F50.2 ICD-10-CM i

Bulimia Nervosa (in remission) – The patient has a historical diagnosis of bulimia nervosa that has been in remission for approximately 4 years.

Procedures

100% Confidence

90791 CPT i

The procedure performed was a comprehensive new patient psychiatric evaluation conducted in an office setting, which aligns with CPT 90791.

Performed By Molly Jahrling
Modifier Value

Performed On 9/8/2025
Units Or Days 1

Schedule Unknown

Reason New patient evaluation for psychiatric care, including assessment of medication-induced sexual dysfunction.

Payer Rules Evaluation

The procedure code 90791, representing a psychiatric diagnostic evaluation, does not match any of the covered endovenous ablation or ultrasound-guided foam sclerotherapy procedures described in the payer rules for symptomatic lower‐extremity chronic venous insufficiency (CVI) and varicose veins. The payer criteria require documentation of limb symptoms, duplex imaging with reflux measurements, CEAP classification, and evidence of conservative therapy failure – none of which are applicable or documented in this psychiatric evaluation. In addition, there is no mapping provided between the psychiatric diagnosis codes (F52.22, F31.9, F41.1, F33.41, F90.0, F50.2, Z91.5) and the vascular conditions required by the payer rules. Prior authorization and associated documentation requirements for the vascular procedure are also completely absent. Therefore, this evaluation does not satisfy the payer's coverage requirements for the specified vascular procedures. Needs Clarification if this was an unintended submission.