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Clario - AI Agent for Medical Coding v1.1

Below is the reformatted clinical note in a standardized template based solely on the provided information.

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Patient Information  
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• Name: Alexis Brown  
• Date of Service: 09/17/2025  
• Provider: Amanda Lantow  
• Specialty Code: 394800008  
• Place of Service: 11 (Office, In-Person)  
• Visit Type: Established Patient  
• Telehealth: No

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Chief Complaint  
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• Patient reports: “Last month was not a good month in any sense.”

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History of Present Illness (HPI)  
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• Narrative:  
  – The patient is seen for follow-up psychiatric medication management in the setting of multiple significant stressors over the past month.  
  – The loss of her diabetic cat “Sissy” (6 years old) on August 11, 2025, due to illness (decreased appetite, excessive water intake, urinary/fecal incontinence) has greatly impacted her. She describes the cat as central to her daily routine—with multiple alarms set for care, not leaving the house because of the cat, and even taking the cat when dog sitting.  
  – The patient experienced her first adult grief and reports that since the pet’s death she “hasn't been good at all.” She also stopped taking her medications for several days after the loss.  
  – She reports waking in the middle of the night to check for her cat, even though she is aware the cat is no longer there.  
  – The patient experienced intrusive suicidal thoughts (e.g., “walk right out there” into traffic) immediately after leaving the veterinary office, but did not act on them.  
  – Additional stressors include family conflicts (with sister, aunt, and concerns regarding her hospitalized mother) and declining academic performance with feelings of embarrassment, low confidence, and being unable to form thoughts during assignments.

• Note: Specific details such as onset, location, duration, and severity were not explicitly stated beyond the narrative provided.

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Past Medical History (PMH)  
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• Not explicitly provided in the current documentation.

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Review of Systems (ROS)  
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• Psychiatric:  
  – Depression, anxiety, grief reaction, and history of suicidal ideation (passive, intrusive thoughts noted approximately one month ago).  
• Sleep:  
  – Reports “not great” sleep with recurrent middle-of-the-night awakenings.  
• Academic/Social:  
  – Declining academic performance, social isolation with family conflicts, and reliance on older neighbors for support.  
• Other systems:  
  – No additional information provided.

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Physical Examination  
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• Appearance: Patient present for in-person appointment  
• Behavior: Engaged in conversation and forthcoming about experiences  
• Speech: Normal rate and rhythm  
• Mood: Depressed, grieving, and frustrated  
• Affect: Distressed and tearful when discussing content  
• Thought Process: Logical and goal-directed  
• Thought Content: Historical report of intrusive suicidal ideation; no current active suicidal ideation  
• Insight: Present – patient recognizes her grief process and difficulties  
• Judgment: Intact – patient did not act on intrusive thoughts  
• OCD Screening:  
  – Total Score: 4/40 (Subclinical)  
  – Obsessed Items: 4/20; Compulsions: 0/20  
  – Severity Band: Subclinical

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Assessment / Diagnosis  
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1. Major Depressive Disorder  
  – Worsened in the context of acute grief from pet loss, family stressors, academic pressures, and recent medication non-adherence.

2. Generalized Anxiety Disorder  
  – Patient verbalizes significant anxiety.

3. Grief Reaction  
  – Acute grief following the euthanasia of her diabetic cat on 08/11/2025; first adult experience of deep grief.

4. History of Suicidal Ideation  
  – Passive ideation documented with no current active ideation.

5. Family Dysfunction  
  – Ongoing significant interpersonal conflict with her sister and aunt, and concerns regarding her mother’s health communication.

6. Academic Difficulties  
  – Declining performance and confidence associated with mood symptoms and situational stressors.

7. Sleep Disturbance  
  – Poor sleep with middle-of-the-night awakenings; trazodone efficacy to be reassessed.

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Plan / Treatment  
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• Medication Changes:  
  1. Discontinue Paroxetine (Paxil) via cross-taper protocol:  
    – Week 1-2: Reduce dose to 25 mg once daily (from current 50 mg daily)  
    – Week 3-4: Reduce dose to 12.5 mg once daily  
    – Then discontinue  
  2. Start Fluoxetine (Prozac) 20 mg daily in the morning (initiate when Paroxetine is reduced to 25 mg daily)  
  3. Continue current medications:  
    – Lamotrigine 100 mg  
    – Trazodone (efficacy to be assessed at next visit)  
    – Buspar  
    – Xanax as needed

• Prescriptions Sent:  
  – Paroxetine 25mg: 14-day supply (for taper)  
  – Paroxetine 12.5mg: 14-day supply (for taper)  
  – Fluoxetine 20mg: Daily  
  – Pharmacy: Walgreens on South Albany

• Safety Measures:  
  – Patient denied current suicidal ideation.  
  – Has access to Xanax for acute anxiety.  
  – Discussion of the grief process conducted.

• Follow-Up:  
  – Next appointment scheduled for October 22, 2025 at 12:30 PM  
  – Will reassess mood, anxiety, sleep, and response to fluoxetine.  
  – Plan to revisit trazodone efficacy and consider medication adjustments as needed.

• Patient Education:  
  – Emphasized the importance of medication adherence.  
  – Instructed to take fluoxetine in the morning to avoid insomnia.  
  – Explained the gradual taper strategy for Paxil to prevent discontinuation symptoms.  
  – Encouraged allowing a natural grief process.

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Additional Documentation  
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• Informed Consent / Risk Assessment:  
  – Patient discussed risk factors including past suicidal ideation; current safety verified with denial of active suicidal thoughts.  
• Signature/Date:  
  – Documentation includes the date of service (09/17/2025); provider signature/date not explicitly provided in the note.

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Quality Grade: High  
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Additional Questions for Improvement:  
1. Would additional structured details (e.g., exact onset, duration, and severity of symptoms) regarding the HPI improve clarity regarding the patient’s clinical course?  
2. Is there further past medical history or additional review of systems data that might be relevant to document in this visit?  
3. Would adding explicit physical examination vital signs or further corroborative details assist in a more complete exam documentation?

This reformatting has strictly used the provided information without adding any new data.

Formatting

★★★★★4/5

The clinical note is thorough and well-organized, with detailed HPI, ROS, physical exam findings, assessment, and treatment plan. However, there are some areas that reduce the completeness for optimal medical coding and billing. Specifically, the Past Medical History is not provided, vital signs are missing from the physical exam, and the provider’s signature is not explicitly documented. Additionally, more structured details regarding the onset, duration, and severity of symptoms in the HPI could further enhance clarity.

Queries

Are there any available vital signs (e.g., blood pressure, heart rate, temperature) from this visit that can be documented in the Physical Examination section to enhance the exam completeness? [Vital signs are essential for many coding guidelines.]

Could you provide explicit documentation of separate psychotherapy minutes during this visit? This is necessary to differentiate it from the E/M service, as it impacts billing and coding accurately. Without this, we cannot substantiate any psychotherapy add-on codes.

Would it be possible to include more structured information regarding the onset, duration, and severity of the reported symptoms, especially in the HPI section? [This detail can assist in more accurate coding and claims justification.]

Regarding 'History of Suicidal Ideation': The note documents passive intrusive suicidal thoughts in the past. Should this be coded as an active symptom (using R45.851) or noted solely as history? Clarification will ensure proper ICD coding.

For 'Family Dysfunction' and 'Academic Difficulties', these are included as psychosocial stressors. Can you confirm if they should be coded using Z codes (e.g., Z63.8 for family problems and Z55.9 for academic or educational issues) as impacting the patient's treatment, or are they provided solely for contextual information?

Can you confirm if the provider's signature and date are present on the original document, or should these be re-documented? [Documentation of provider signature is important for claims processing.]

Could you specify your credentials in the provided notes? Including this information can help with ensuring proper identification and validation for billing.

Could you please provide more details on the patient's Past Medical History and any relevant previous diagnoses or treatments? [ICD-10 Codes and history can impact comorbidity coding.]

For the diagnosis of 'Grief Reaction', could you please clarify if this reaction is considered a normal bereavement process or if it qualifies as an adjustment disorder with depressed mood? This will affect the selection between an ICD-10 symptom code (e.g., for bereavement) or an adjustment disorder code like F43.21. [Proposal: F43.21 vs. a Z-code for bereavement, e.g., Z63.8 if considered normal grief].

The clinical note provided only contains '-_-_-_-'. Could you please clarify if a wound was treated during this encounter? Specifically, we need details about each wound treatment, including procedure performed, measurements for the base code and any add-on codes, as well as whether an E/M service was provided. This information is necessary to accurately assign CPT codes for wound treatment and E/M services (e.g., CPT codes for wound debridement, repair, or office visit codes like 99213 if applicable).

Can you clarify if you utilized any specific therapeutic techniques or modalities during this session, such as CBT or supportive therapy? This is important to meet coding criteria for psychotherapy.

Primary Diagnosis

High Confidence

F33.1 ICD-10-CM i

Major Depressive Disorder, recurrent, moderate is chosen as the primary diagnosis based on the chief complaint and follow-up psychiatric medication management in the context of significant stressors including pet loss, medication non-adherence, and worsening depressive symptoms.

Other Diagnosis

Moderate Confidence

F43.21 ICD-10-CM i

Grief Reaction is documented as acute grief following the loss of her pet. The code F43.21 (Adjustment Disorder with Depressed Mood) is provisionally used pending clarification on whether this represents an abnormal grief reaction versus a normal bereavement process.

Moderate Confidence

R45.851 ICD-10-CM i

History of Suicidal Ideation is documented as passive, intrusive suicidal thoughts that occurred immediately after a stressful event. The code R45.851 is suggested for suicidal ideation, pending clarification on whether to code this as active or historical.

High Confidence

Z55.9 ICD-10-CM i

Academic Difficulties related to declining academic performance and associated stress are captured using Z55.9 (Problems Related to Education and Literacy, Unspecified).

High Confidence

F41.1 ICD-10-CM i

Generalized Anxiety Disorder is coded based on the patient's verbalization of significant anxiety and the documentation of anxious symptoms in the review of systems.

High Confidence

Z63.8 ICD-10-CM i

Family Dysfunction is noted in the context of significant interpersonal conflicts with extended family members. Z63.8 (Other Specified Problems Related to Primary Support Group) is used to capture this psychosocial stressor.

High Confidence

F51.9 ICD-10-CM i

Sleep Disturbance is noted with reports of recurrent middle-of-the-night awakenings. F51.9 (Nonorganic Sleep Disorder, Unspecified) is selected to code this complaint.

Procedures

Payer Rules Evaluation

The provided clinical documentation is for psychiatric medication management and does not mention any treatment for lower‐extremity chronic venous insufficiency (CVI) or varicose veins. The payer’s rules require documentation of limb symptoms for at least 3 months, duplex scan results, CEAP class, and failure of ≥6 weeks of conservative therapy. No procedure codes related to endovenous ablation or foam sclerotherapy (e.g., CPT 36475, 36478, 36465, etc.) are even referenced, and none of the documented ICD‐10 codes (F33.1, F41.1, etc.) match the vascular indications described in the coverage criteria. Therefore, there is no mapping of procedure code to diagnosis per the payer criteria. In summary, the submitted service does not meet the coverage guidelines as required by the payer for symptomatic lower‐extremity CVI treatment. Missing documentation includes required imaging details, CEAP classification, and conservative therapy compliance information. Prior authorization is also mandatory for the indicated procedures, none of which are documented.