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Clario - AI Agent for Medical Coding v1.1

Patient Information
- Patient Name: Adam Wallace  
- Date of Service: 01/28/2026  
- Provider NPI: 12  
- Provider Specialty Code: 394800008  
- Visit Type: In-person

Chief Complaint
Follow-up psychiatric medication management appointment for PTSD, depression, and anxiety. Patient is also requesting a trial of clonazepam for upcoming travel.

History of Present Illness (HPI)
Mr. Wallace is an adult male presenting for follow-up after his last appointment on February 3rd. He reports self-adjusting his aripiprazole dose from 2 mg to 4 mg since the last visit and is satisfied with the increase.

Depression:  
- Describes his depression as "a little better" compared to the previous visit.  
- Reports decreased feelings of apathy, improved enjoyment of activities, and increased engagement in his marriage.  
- Expresses hope that warmer weather will further improve his mood.

Suicidal Ideation:  
- Experiences fleeting, passive suicidal thoughts ("morbid thoughts about escaping from society" such as living in a car alone) that occur with decreased frequency.  
- Denies any intent or plan to act on these thoughts and states they are “easy to shake off.”

Emotional Reactivity/Irritability:  
- Feels more in control of his anger since increasing aripiprazole.  
- Indicates he is better able to reflect on his feelings before reacting, with only occasional, mild overreactions during arguments.

Anxiety/PTSD Symptoms:  
- Continues to struggle with crowds and experiences hypervigilance in busy settings, scanning for exits and conducting continuous threat assessments.  
- Endures flashbacks (primarily as nightmares) a couple of times per week with triggers including loud noises, bright light reflections, smells, truck brakes, and routine changes.  
- Experiences a prominent startle reflex and occasional feelings of unreality/dissociation a few times per week.  
- Baseline anxiety is manageable, although it escalates quickly with trauma-related triggers.  
- Panic attacks occur 0-1 times per week; grounding techniques and walking help alleviate these episodes.  
- Reports moderate racing thoughts, ruminations, and catastrophizing.

Work/Occupational Functioning:  
- Reports difficulty with concentration at his current desk job, particularly during periods of inactivity.  
- Expresses a desire for a more kinetic work environment and is seeking enrollment in the VA vocational rehabilitation program for career counseling and potential career change.

Sleep:  
- Noted improved sleep quality with a new CPAP machine and better tolerance of the new mask.  
- Sleeps approximately 6–8 hours per night with fewer interruptions.  
- Has been taking trazodone 50 mg at bedtime but is now agreeable to increasing the dose to 75 mg.

Energy/Motivation:  
- Improved energy attributed to better quality sleep.

Appetite/Weight:  
- Describes appetite as “okay.”  
- Tends to overeat and prefers poor snack choices high in salt, sugar, and carbohydrates.  
- Weight is stable despite a previous 30-pound gain over several years.  
- Hopes warmer weather will lead to increased activity and weight management.

Exercise:  
- Walks his dog 2–3 times daily (approximately 2–3 miles total).  
- Plans to increase walking distance and duration with longer daylight and warmer weather.

Past Medical History (PMH)
- Medical Conditions:  
  - Prediabetes  
  - Obstructive Sleep Apnea (currently using CPAP)
- Substance Use:  
  - Cigarettes: None  
  - Alcohol: Very rare use  
  - Marijuana: Uses typically morning and nighttime for pain and anxiety  
  - Caffeine: Consumes soda and energy drinks several days per week (currently attempting to reduce intake)
- Therapy:  
  - Ongoing therapy with Christie (reports a good therapeutic fit)

Review of Systems (ROS)
- Psychiatric: Depression, anxiety, PTSD symptoms, irritability, and passive suicidal ideation.  
- Sleep: Improved sleep quality with CPAP, sleeps 6–8 hours per night.  
- Appetite: Normal with tendency to overeat; cravings for salt, sugar, and carbohydrates.  
- Energy: Improved energy levels.  
- Neurological: Occasional flashbacks, startle reflex, and dissociative feelings.  
- Occupational: Difficulty concentrating and dissatisfaction with current work environment.

Physical Examination
 Mental Status Examination
- Appearance: Not documented  
- Behavior: Cooperative and engaged  
- Speech: Normal rate and rhythm, goal-directed  
- Mood: Not explicitly stated  
- Affect: Appropriate to content  
- Thought Process: Linear and logical  
- Thought Content: Endorses fleeting passive suicidal ideation without intent or plan; morbid thoughts about escaping present but decreased in frequency; no homicidal ideation noted  
- Perception: No active psychosis observed  
- Cognition: Intact based on conversation  
- Insight: Good—patient is aware of his symptoms and seeks treatment modifications  
- Judgment: Good—manages medications appropriately and is proactive in treatment

OCD Assessment
- Severity Band: Mild  
- Total Score: 10/40  
- Obsessions Subscore: 4/20  
- Compulsions Subscore: 6/20

Assessment / Diagnosis
1. Post-Traumatic Stress Disorder (PTSD):  
   - Persistent symptoms including hypervigilance, nightmares, flashbacks, dissociative episodes, and trauma-related triggers.  
   - Ongoing functional impairment in crowded settings.  
   - Some improvement in emotional reactivity following aripiprazole dose adjustment.

2. Major Depressive Disorder:  
   - Mild improvement in depressive symptoms with decreased apathy and increased engagement in life and relationships.  
   - Persistent fleeting passive suicidal ideation without intent or plan; overall improvement noted.

3. Generalized Anxiety Disorder:  
   - Manageable baseline anxiety with escalation during trauma-related triggers and moderate racing thoughts.  
   - Occasional panic attacks (0-1 per week) addressed with grounding techniques.

4. Irritability/Mood Dysregulation:  
   - Improved control over anger symptoms attributed to increased aripiprazole dose.

5. Obstructive Sleep Apnea:  
   - Improved sleep quality and compliance with the use of a new CPAP machine.

6. Prediabetes:  
   - Stable condition; weight is stable despite previous gain.

7. Obsessive-Compulsive Disorder (OCD) Symptoms:  
   - Mild symptoms based on assessment score (10/40).

Plan / Treatment
 Medications
1. Aripiprazole:  
   - Increase the dose from 2 mg to 5 mg daily in the morning.  
   - Patient has been self-adjusting to 4 mg with good effect; due to tablet availability, switching to 5 mg is indicated.  
   - Use remaining 2 mg tablets before transitioning to 5 mg.  
   - Sent to CVS at Target on Sycamore Road.

2. Trazodone:  
   - Continue 50 mg at bedtime.  
   - Patient may increase to 75 mg as discussed, with VA supplying the medication.

3. Sertraline:  
   - Continue 100 mg daily.  
   - Monitor for future need for adjustment; VA continues supply.

4. Clonazepam 0.5 mg: (New Prescription)  
   - Take 1–2 tablets as needed for travel anxiety (maximum 2 tablets per day).  
   - Dispense 30 tablets.  
   - Patient Education:  
     - Do not combine with alcohol, marijuana, or opioid/narcotic pain medications due to risk of respiratory depression, confusion, slowed processing, impaired gait, and increased fall risk.  
     - Onset is approximately 30–60 minutes with a duration of about 8 hours.  
     - If taking two doses in a day, space them at least 8 hours apart.  
     - For the first dose, remain in a safe location and avoid driving for 3–4 hours until effects are known.  
     - Avoid taking the first dose immediately before bed to assess daytime response.  
     - Benzodiazepines are for short-term, as-needed use only due to risks of tolerance, dependence, and misuse.  
     - Long-term use can disrupt sleep, lower mood, and increase anxiety; if daily use becomes necessary, reassessment of medications is warranted.

Therapy
- Continue ongoing therapy with Christie.

Follow-up
- Next appointment scheduled for Monday, July 14th at 5:30 PM (approximately 3 months from the visit).  
- Plan to reassess symptoms, review response to medication adjustments, evaluate the effect of seasonal change, and review plans prior to the August trip.

Safety and Risk Assessment
- Patient denies any suicidal intent or plan.  
- Passive suicidal ideation is fleeting and manageable.  
- Patient is encouraged to reach out if symptoms worsen or if any concerns arise before the next appointment.

Additional Documentation
- Informed Consent: Not explicitly documented but assumed from the treatment discussions and patient education provided, particularly regarding the new controlled substance (clonazepam).  
- Risk Assessment: Documented review of passive suicidal ideation, with clear patient report of no imminent risk.  
- Signature/Date: Documentation includes date of service 01/28/2026. (Provider signature not explicitly provided in the text.)

Quality Grade
Grade: High

Additional Questions for Improvement
1. Would additional details on the physical examination (e.g., vital signs, additional pertinent findings) be beneficial in future documentation?
2. Is further clarification on the patient’s mood (beyond affect) desired for enhanced clarity?
3. Would including explicit informed consent for medication changes improve documentation quality?

Formatting

★★★★★5/5

The clinical note is comprehensive with detailed documentation on the History of Present Illness, a thorough Mental Status Examination, clear assessment and diagnosis, and an extensive treatment plan including medication doses and patient education. The documentation clearly addresses the chief complaint and risk assessment. Although minor areas like explicit vital signs and a clear written informed consent signature could further improve the note, overall it is robust for medical coding, billing, and claims processing.

Queries

Would you be able to clarify and document the patient's mood status explicitly (in addition to affect) during the Mental Status Examination for enhanced clarity? This could further support the coding for psychiatric evaluation.

Could you please confirm if there are additional details regarding the patient's vital signs or further physical exam findings? This information could help determine if any additional modifiers or E/M code complexities (such as CPT 99214 modifiers) are applicable for a more accurate coding of the office visit.

Could you provide additional details regarding vital signs or any other pertinent physical exam findings that were measured during the visit? This information can be useful for codes related to the physical exam (e.g., blood pressure, heart rate).

Please confirm if explicit informed consent for medication changes, especially for the new controlled substance (clonazepam), was obtained and documented in a signed form. This clarification is important for proper documentation of consent-related billing codes.

Primary Diagnosis

95% Confidence

F43.10 ICD-10-CM i

The primary diagnosis is Post-Traumatic Stress Disorder. The notes indicate persistent PTSD symptoms (hypervigilance, nightmares, flashbacks, dissociation) which are the chief focus of the visit, making F43.10 (PTSD, unspecified) the most appropriate and specific code.

Other Diagnosis

95% Confidence

R73.03 ICD-10-CM i

Prediabetes is noted in the patient’s past medical history and is being managed. R73.03 is the precise ICD-10 code for prediabetes conditions.

95% Confidence

F41.1 ICD-10-CM i

Generalized Anxiety Disorder is noted with manageable baseline anxiety and occasional panic attacks. F41.1 is specific for Generalized Anxiety Disorder.

95% Confidence

F33.0 ICD-10-CM i

Major Depressive Disorder is documented with mild improvement in symptoms. F33.0 is used for Major Depressive Disorder, recurrent, mild, which aligns with the description provided.

90% Confidence

F42.9 ICD-10-CM i

Obsessive-Compulsive Disorder symptoms are documented as mild based on the OCD assessment score. F42.9 (unspecified OCD) is used since the patient displays subthreshold or mild symptoms.

95% Confidence

G47.33 ICD-10-CM i

Obstructive Sleep Apnea is documented with improved sleep quality using CPAP. G47.33 is the appropriate ICD-10 code for obstructive sleep apnea in adults.

Procedures

Payer Rules Evaluation

The payer rules provided pertain exclusively to endovenous ablation/foam sclerotherapy for symptomatic lower‐extremity chronic venous insufficiency/varicose veins. None of the procedure codes associated with these treatments (36475, 36476, 36478, 36479, 36465, 36466) are present. Instead, the clinical documentation relates solely to psychiatric management and medication adjustments. There is no mapping of a procedure code to a venous diagnosis, and none of the clinical criteria (e.g., 3 months of symptoms, duplex imaging with reflux measurement, appropriate CEAP class, or conservative therapy trial) are documented to support the covered services. Furthermore, no prior authorization or modifier requirements related to ablation or sclerotherapy are addressed as the services requested do not fall under the covered category in the payer rules. As a result, from a payer rules perspective for varicose vein procedures, the submitted service is not compliant.