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Clario - AI Agent for Medical Coding v1.1

Below is the reformatted clinical note based on the provided checklist:

Patient Information

- Name: Chelsea Sarikas  
- Age/Sex: 26-year-old Female  
- Provider: Megan Becker  
- Specialty: 394800008  
- Date of Service: August 8, 2025  
- Visit Type: Established Patient  
- Place of Service: Office (11)  
- Telehealth: No

Chief Complaint

Follow-up for OCD and medication management

History of Present Illness (HPI)

The patient is a 26-year-old female with obsessive-compulsive disorder (OCD) presenting for a follow-up appointment approximately one month after an increase in her Prozac (fluoxetine) dosage. She describes her mood as "pretty normal" without noticeable flatness. The patient reports that work has been particularly stressful during this period, describing it as "a little crazy" and "nightmarish" due to additional responsibilities beyond her usual duties.

Key Details:
- Onset & Duration: Symptoms noted over the past month following medication adjustment.  
- Character: OCD symptoms include increased negative intrusive thoughts about herself and her body image, specifically recurring thoughts about purchasing a scale.  
- Associated Behaviors: Notable hair picking behavior with one episode lasting approximately one hour, longer than her typical pattern.  
- Severity: Approximately 4 days over the past month have been worse than baseline.  
- Aggravating Factors: Increased work stress appears to be exacerbating her symptoms.  
- Relieving Factors: The new dose of Prozac, though she reports no noticeable improvement yet (acknowledging it is early in the adjustment process).

- Additional Symptom Detail:
  - Eating/Body Image: Denies purging behaviors; appetite and eating habits remain "pretty normal." However, she feels not ready to engage with a nutritional referral given the risk of "weaponizing" nutritional guidance amid intrusive thoughts.
  - Anxiety: Elevated, noticeably related to occupational stress.
  - Sleep: Generally “pretty fine” with occasional difficulty falling asleep; she uses magnesium (200-400mg) nightly. She has not experienced significant improvement with magnesium and prefers not to resume hydroxyzine.

- Medication Tolerability: Reports mild nausea during the first few days after the dose increase, which resolved.

- Psychotherapy: Continues weekly therapy with Anna and has initiated additional trauma-focused sex therapy, having completed one session with plans for a second.
  
- Relationship: Reports a good relationship with her boyfriend, despite some anxiety about a pending conversation regarding her OCD manifestations.

Past Medical History (PMH)

- Obsessive-Compulsive Disorder (OCD)
- Anxiety Symptoms (related to occupational stress)
- Body Image Concerns/Disordered Eating History (currently stable without active purging concerns)

Note: Additional historical details (e.g., other chronic illnesses) are not provided in the note.

Review of Systems (ROS)

- Psychiatric:  
  - Mood: Reports stable mood ("pretty normal"), no flatness.  
  - Intrusive Thoughts: Increased, negatively focused on self-image.  
  - Anxiety: Elevated, particularly in relation to work stress.

- Sleep:  
  - Occasional difficulty initiating sleep but generally adequate sleep quality.

- Gastrointestinal:  
  - Transient mild nausea after Prozac dose increase (resolved).  
  - Appetite: Remains normal.

- Eating/Body Image:  
  - No purging behaviors reported.

Other systems are not documented or are negative.

Physical Examination

Encounter Type: In-person office visit

- General/Behavior:  
  - Appearance: Not formally documented  
  - Behavior: Engaged appropriately in conversation

- Mental Status Examination:  
  - Speech: Normal rate and rhythm, appropriate.  
  - Mood: Described by patient as "pretty normal"  
  - Affect: Appropriate to content  
  - Thought Process: Linear and goal-directed  
  - Thought Content: Intrusive thoughts regarding body image and self-criticism; denies current suicidal or homicidal ideation.  
  - Insight: Good; recognizes triggers and impact on OCD symptoms  
  - Judgment: Good; actively engaged in treatment options

Vital signs and other physical exam findings were not provided in the clinical note.

Assessment / Diagnosis

1. Obsessive-Compulsive Disorder (OCD):  
   - Status: Stable to slightly worsened; exacerbated by increased work stress.  
   - Clinical Reasoning: Despite a recent increase in Prozac, the patient continues to experience intrusive thoughts and prolonged hair picking episodes.

2. Anxiety Symptoms:  
   - Status: Elevated, linked to occupational stress.

3. Body Image Concerns with Intrusive Thoughts:  
   - Status: Ongoing, contributes to overall OCD symptomatology.

4. History of Disordered Eating:  
   - Status: Stable; no active purging behaviors and nutritional referral deferred.

5. Sleep Disturbance:  
   - Status: Mild difficulty initiating sleep; managed with magnesium supplementation.

Plan / Treatment

1. Medication Management:
   - Fluoxetine (Prozac) 40mg:  
     - Continue current dose with a one-month supply sent to the pharmacy.  
     - Plan to reassess efficacy at the next visit.
   
   - Magnesium Supplementation:  
     - Increase dosage to 400mg nightly.  
     - Advise taking magnesium 1–2 hours before bedtime to optimize its effect for sleep initiation.
   
2. Psychotherapy:
   - Continue weekly therapy sessions with Anna.
   - Continue trauma-focused sex therapy (approximately twice per month), given current scheduling constraints.

3. Nutritional Referral:
   - Deferred at this time due to patient concerns about triggering intrusive thoughts.  
   - Option to revisit in the future.

4. Pharmacogenomic Testing:
   - Discussed GeneSight testing as an option for future medication adjustments.
   - Patient has been informed previously but has not completed testing.

5. Monitoring:
   - Reassess symptoms in 6 weeks.
   - If there is no improvement in OCD symptoms by then, consider further dose increase of Prozac or a potential medication change, possibly guided by pharmacogenomic testing.

6. Safety Measures:
   - Instruct patient to contact the provider if any concerns arise prior to the next appointment.

7. Follow-up Appointment:
   - Telehealth follow-up scheduled for September 12, 2025, at 8:15 AM.

Additional Documentation

- Informed Consent: Obtained for ongoing treatment and any potential medication adjustments.
- Risk Assessment: Patient denies suicidal or homicidal ideations. Continues to demonstrate good insight and judgment.
- Signature/Date: Megan Becker, MD – August 8, 2025

Quality Grade: A

Questions for Improvement:  
- Are any additional past medical or surgical history details available to further contextualize the patient’s overall health?  
- Would including current vital signs and physical exam details (if available) improve the comprehensiveness of the documentation?  
- Is there any additional information regarding the patient's functional status or daily living activities that may be relevant?

Please advise if further modifications or additional details are needed.

Formatting

★★★★★4/5

The clinical note is overall detailed and structured, providing comprehensive information such as patient demographics, HPI, ROS, assessment, and plan which can support coding, billing, and claims processing. However, there are minor gaps such as the absence of documented vital signs and additional physical exam details which, if included, would further enhance the note’s completeness for coding purposes.

Queries

Are there any additional past medical or surgical history details, or relevant lab/imaging results that could be documented to further contextualize the patient’s overall health status? (This information can support ICD coding for comorbid conditions.)

Could you provide the patient's current vital signs and any other pertinent physical exam details (e.g., blood pressure, heart rate, temperature) to complete the physical examination section? (Codes: CPT 99214 or similar may require vital sign documentation.)

For the 'Body Image Concerns with Intrusive Thoughts' noted in the assessment, should this be coded as a separate diagnosis (e.g., Body Dysmorphic Disorder [F45.22] if applicable) or is it intended to be documented as part of her OCD symptoms? Clarification will help ensure we select the most specific ICD code.

Primary Diagnosis

95% Confidence

F42.2 ICD-10-CM i

The primary diagnosis is Obsessive-Compulsive Disorder. The patient’s chief complaint is a follow-up for OCD with increased intrusive negative thoughts and hair picking episodes. F42.2 is chosen to reflect a mixed presentation of obsessions and compulsions as documented.

Other Diagnosis

90% Confidence

G47.00 ICD-10-CM i

Mild sleep disturbance with occasional difficulty initiating sleep is noted. G47.00 (Insomnia, unspecified) is selected to document the sleep issue accompanying her overall condition.

85% Confidence

Z87.121 ICD-10-CM i

The patient’s past history of disordered eating (with no current purging behaviors) is documented. Z87.121 (Personal history of eating disorder) is used to capture this aspect of her history.

90% Confidence

F41.9 ICD-10-CM i

Anxiety symptoms related to occupational stress are present. F41.9 (Anxiety disorder, unspecified) is used given the non-specific nature of her anxiety presentation.

Procedures

Payer Rules Evaluation

The current documentation is for a psychiatric follow‐up appointment for OCD management and does not include any procedure codes for endovenous ablation or ultrasound‐guided foam sclerotherapy for symptomatic lower-extremity CVI/varicose veins. The associated ICD‐10-CM codes (F42.2, F41.9, G47.00, Z87.121) do not align with the CVI criteria required for the covered procedures, which reference specific venous disease diagnoses. Additionally, there is no documentation of the necessary clinical presentation, imaging findings, CEAP classification, or conservative therapy details that would support CVI treatment. As both the mapping of procedure codes to diagnosis codes and the required documentation for CVI criteria are absent, it needs clarification whether there was an intended coverage request for the CVI treatments. Thus, the provided documentation does not satisfy the coverage rules for the procedures in question.