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Clario - AI Agent for Medical Coding v1.1

Below is the reformatted clinical note following the requested standardized template. Note that only information provided in the original note has been included. Some sections (e.g., Past Medical History, Review of Systems, vital signs in Physical Examination) did not have data provided in the original note and are noted as “Not Documented.”

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Quality Grade: High

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Patient Information  
• Gender: Male  
• Date of Service: 07/29/2025  
• Provider: Michael McDowell, Nurse Practitioner (394800008)  
• Place of Service: Office (11 – In-Person)

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Chief Complaint  
Follow-up visit for an established patient in the treatment program; covering for regular provider Dina for this week.

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History of Present Illness (HPI)  
• Narrative: The patient is a male approximately 3‑4 weeks into the treatment program. He reports that group sessions have been “fine” and that he has been actively speaking during sessions.  
• Onset/Duration: Approximately week 3-4 in program  
• Severity:  
 – Anxiety: Currently rated 5/10 (improved from 7/10 last week)  
 – Depression: Currently rated 6/10 (unchanged)  
• Character:  
 – Anxiety and depression symptoms remain present with slight improvement in anxiety.  
 – Sleep disturbance characterized by chronic sleep onset insomnia (difficulty falling asleep).  
• Associated Factors:  
 – Patient reports that his medication (Colmate taken twice daily – morning and bedtime) is helping “a little bit.”  
 – Subjectively notes passive self-harm thoughts described as “a tiny bit” without plan or intent.  
• Additional Details:  
 – Eating behaviors: Reports doing “good” with the eating plan, although he has difficulty finishing entire meals (approximately 80% completion in the program), while eating more at home compared to the in-program setting.

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Past Medical History (PMH)  
Not Documented

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Review of Systems (ROS)  
Not Documented in detail; however, note the following from the mental health review:  
• Sleep: Difficulty with sleep onset (insomnia)  
• Mood: Anxiety and depression present; passive self-harm ideation noted  
• Eating: Difficulty finishing meals during in-program sessions; improvement when eating at home

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Physical Examination  
• Mental Status Examination:  
 – Appearance: Engaged in session  
 – Behavior: Cooperative; briefly stepped away during session to answer a question  
 – Speech: Normal  
 – Mood: Not explicitly stated  
 – Affect: Appropriate to conversation  
 – Thought Process: Linear and coherent  
 – Thought Content: Endorses passive self-harm ideation without plan or intent  
 – Cognition: Alert and oriented  
 – Insight/Judgment: Appears intact and engaged in the treatment program  
• Vital Signs: Not Documented  
• Other Physical Findings: None documented

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Assessment / Diagnosis  
1. Anxiety disorder  
 • Clinical Reasoning: Improvement documented (5/10 from previous 7/10) based on self-report.  
2. Depressive disorder  
 • Clinical Reasoning: Symptoms remain stable at 6/10 based on patient’s self-report.  
3. Sleep disturbance (chronic sleep onset insomnia)  
 • Clinical Reasoning: Ongoing difficulty with sleep onset noted as a longstanding issue.  
4. Eating disorder (in treatment program)  
 • Clinical Reasoning: Patient shows improvement when eating at home but continues to struggle with completing meals during in-program sessions, with documented approximately 80% meal completion.  
5. Passive self-harm ideation  
 • Clinical Reasoning: Patient reports “a tiny bit” of self-harm thoughts without plan or intent, with no acute risk identified.

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Plan / Treatment  
1. Medications  
 • Continue current Colmate twice daily (morning and bedtime); patient reports this provides some benefit.  
2. Program Participation  
 • Continue current treatment program participation with group sessions.  
3. Eating Plan  
 • Reinforce the importance of completing meals while continuing the current meal plan.  
4. Safety/Mental Health  
 • Continue to monitor passive self-harm ideation; no acute safety concerns identified at this time.  
5. Follow-Up  
 • Regular provider (Dina) scheduled to resume care next week; information from today’s visit will be communicated to the regular provider.  
6. Patient Education  
 • Patient verbalized no questions or concerns at this time.

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Additional Documentation  
• Informed Consent: Not specifically documented.  
• Risk Assessment: Documented via safety assessment (denied suicidal/homicidal ideation; passive self-harm thoughts noted with no intent or plan).  
• Provider Signature/Date: Michael McDowell / 07/29/2025

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Additional Questions for Improvement  
• Would inclusion of objective vital signs enhance the physical examination section?  
• Are there any further details regarding the patient’s Past Medical History or additional Review of Systems that should be included to enrich the note?  
• Is there any documentation of informed consent available that should be appended to the note?

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End of Note

Formatting

★★★★★4/5

The clinical note is comprehensive in its coverage of the History of Present Illness, Mental Status Examination, Assessment, and Treatment Plan. It includes detailed self-reported symptoms and treatment details, which is helpful for billing and claims processing. However, the note is missing documented Past Medical History, objective vital signs in the Physical Examination section, and explicit documentation of informed consent, which can be important for complete coding.

Queries

Is there additional documentation of informed consent available that can be appended to the note? This documentation is important for both legal and coding purposes, especially if any procedures or treatment modifications were discussed.

In the Mental Status Examination section, could you provide an explicit statement regarding the patient's mood? This is essential for complete documentation of the mental status assessment.

The provided encounter note '-_-_-_-' does not specify any details about wound treatment, wound measurements, or any procedure performed on a wound. Could you please clarify if any wounds were treated during this encounter and, if so, what specific treatment was performed (including details on measurement to determine base and add-on codes)? Also, please confirm if an Evaluation & Management (E&M) service was performed as part of this encounter. This clarification is needed to determine whether to apply a CPT procedure code for wound treatment or an E&M code (e.g., CPT codes for office or consultation services), and to avoid billing for procedures that were not performed. [Related Codes: wound treatment procedure codes, E&M CPT codes]

Could you clarify whether any specific therapeutic interventions were planned or discussed in this session? This information is necessary to determine the applicability of psychotherapy codes.

Do you have any explicit time statements indicating the duration of the therapeutic intervention or session? The notes state a session duration but do not specify any time allocated to psychotherapy, which is necessary for accurate coding.

Was there a specific continuation plan discussed regarding depression given its current stable status? Clarifying this in the notes can help outline ongoing care and support.

The instructions indicate that procedure codes should be added for each wound treated during this encounter based on the procedure performed including measurements to determine base and add-on codes. However, the provided notes do not include specific details on any wound treatment (measurement, debridement, dressing changes, etc.) or any E&M service documentation. Could you please clarify if any wounds were indeed treated during this encounter? If yes, please provide details on: (a) the number of wounds treated, (b) the specific procedures performed on each wound (e.g., debridement, dressing, suturing), (c) measurements of the wound dimensions, and (d) if any E&M procedures were performed. This clarification is needed to accurately assign the appropriate CPT codes for wound management and E&M services (e.g., wound debridement base codes, add-on codes, and E/M codes) as per guidelines.

Can you elaborate on the patient's mood during the session? A more detailed observation of mood would assist in coding for depression accurately (e.g., was the mood reported as sad, irritable, etc.?).

Can you confirm whether this visit was solely for medication management or if any psychotherapy techniques were utilized? This will directly influence the coding for this encounter.

Please provide any relevant details for Past Medical History (PMH), such as previous diagnoses, surgeries, or ongoing conditions, to enhance the completeness of the coding documentation.

The provided note only includes procedural instructions regarding wound treatment but does not specify any details about actual wound treatments or wound measurements. Could you please clarify if any wounds were actually treated during this encounter, and if so, provide details of each wound (e.g., location, measurements, type of treatment performed) so that the appropriate base and add-on CPT codes can be assigned? Additionally, please confirm if an E&M code is applicable for this encounter.

Could you provide details on any specific therapeutic interventions or techniques used during this visit? As noted, there are no therapeutic modalities documented which may affect billing and descriptive accuracy. Codes 90833/90836/90838 apply only when psychotherapy is performed, and there is currently no documentation to support this.

Could you confirm if there are any objective vital signs (e.g., blood pressure, heart rate, temperature) available from today’s visit? This information is useful for the Physical Examination section and proper evaluation and management coding.

For the diagnosis of passive self-harm ideation, could you please clarify if you would like this to be coded as R45.851 (Suicidal Ideation) or if there is a more specific code you prefer for passive self-harm thoughts? This clarification is needed to ensure accurate ICD-10 coding as the clinical note documents only passive self-harm ideation without plan or intent.

Is there any follow-up plan regarding the patient's passive self-harm ideation? Although the notes discuss this, a clear safety plan documenting the provider's response to this concern would enhance completeness and aid in coding.

Primary Diagnosis

95% Confidence

F41.9 ICD-10-CM i

The primary diagnosis is anxiety disorder as it is a chief complaint component of the follow‐up in the treatment program. F41.9 (Anxiety Disorder, Unspecified) is chosen based on the fact that the patient’s anxiety, though improving (rated 5/10 from 7/10), remains a significant component of his current condition.

Other Diagnosis

90% Confidence

F50.9 ICD-10-CM i

An eating disorder is mentioned, particularly in the context of the treatment program where the patient shows improvement in eating at home versus during sessions. F50.9 (Eating Disorder, Unspecified) is chosen due to the lack of further specification in the note.

90% Confidence

F33.9 ICD-10-CM i

Depressive disorder is documented with symptoms remaining stable at 6/10. F33.9 (Major Depressive Disorder, Recurrent, Unspecified) is used because the note does not provide enough specificity to indicate a particular subtype.

80% Confidence

R45.851 ICD-10-CM i

Passive self-harm ideation is documented in the note as 'a tiny bit' without any plan or intent. R45.851 (Suicidal Ideation) is provisionally assigned pending clarification since there is no distinct ICD code for passive self-harm ideation; please advise if an alternative coding is preferred.

90% Confidence

G47.00 ICD-10-CM i

Chronic sleep onset insomnia is noted under the sleep disturbance description. G47.00 (Insomnia, Unspecified) is used here to capture the ongoing difficulty initiating sleep.

Procedures

Payer Rules Evaluation

This claim does not meet the payer’s covered indication requirements. The payer rules require procedures for symptomatic lower-extremity chronic venous insufficiency/varicose veins with supporting diagnostic imaging, a varicose vein ICD‐10 diagnosis (e.g., I83.x series) and documentation of ≥ 3 months of symptoms along with a trial of conservative therapy. The provided clinical note is a mental health follow‐up with ICD‑10 codes related to anxiety, depression, sleep disturbance, and eating disorder. There is no documentation of limb symptoms, duplex imaging with reflux measurements, CEAP classification or compression therapy compliance for venous disease. In addition, there are no procedure codes provided that would map to the indications described by the payer. As a result, none of the required criteria (A–D) are met for the covered procedures. Needs Clarification regarding whether a separate venous evaluation has been performed.