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Clario - AI Agent for Medical Coding v1.1

Below is the reformatted clinical note following the requested standardized template:

─────────────────────────────────────────────  
 Patient Information  
- Date of Service: 07/31/2025  
- Place of Service: Office/Outpatient (11)  
- Visit Type: New Patient  
- Telehealth: No  
- Patient Gender: Female  
- Provider: Megan Becker  
- Specialty: Psychiatry (394800008)

─────────────────────────────────────────────  
 Chief Complaint  
Patient presents as a new patient requesting refills of propranolol and reporting increased anxiety and difficulty sleeping over the past week to two weeks.

─────────────────────────────────────────────  
 History of Present Illness (HPI)  
Anne Zheng is a female patient here for an initial psychiatric evaluation. She reports needing a refill of propranolol 10mg, which she has been taking as needed for anxiety, primarily before presentations and social situations. Over the past one to two weeks, she has experienced increased nighttime anxiety with an elevated heart rate disrupting sleep. The medication, which she last refilled about a year ago, is still helpful for calming her symptoms when taken at night.

Additional details include:  
- Onset & Timing: Symptoms worsened over the past one to two weeks.  
- Duration: Multiple nights with difficulty falling asleep.  
- Character: Increased anxiety at night associated with racing heart rate.  
- Aggravating/Relieving Factors: Propranolol helps slow heart rate and reduce anxiety; she also uses propranolol before high-pressure social situations.  
- Severity: Rates her current depression symptoms as 8/10 compared to her baseline of 2/10.  
- Narrative: She describes a long-standing history of anxiety and depression with fluctuating symptoms. She also notes her menstrual cycle may sometimes affect her mood, with her last period beginning July 5th and an expected imminent onset of the next period.

─────────────────────────────────────────────  
 Past Medical History (PMH)  
 Psychiatric History  
- Diagnoses: Anxiety and depression (previously diagnosed)  
- Previous Medications and Responses:  
  - Lexapro (escitalopram): Approximately 6 months use; ineffective.  
  - Abilify (aripiprazole): Added for depression; caused excessive sedation and was discontinued.  
  - Propranolol 10mg PRN: Currently in use with benefit for anxiety.  
- Therapy: Limited brief therapy during college via university counseling services (not helpful) and currently not pursuing therapy.

Eating Disorder History  
- History: Bulimia nervosa during college, onset around age 20.  
- Current Status: In remission (last purging behavior over one year ago); continues behaviors such as daily calorie tracking and weighing.  
- Additional Notes: Exercises extensively (up to three hours combining weightlifting and rock climbing).

Medical History (Other)  
- Gynecological:  
  - Abnormal Pap smear cells identified requiring biopsy (in Michigan).  
  - Copper IUD placed five weeks ago.  
- General Medical:  
  - Denies other underlying health conditions.  
  - Minor childhood surgery for a cut (no general anesthesia noted).  
  - Last physical with bloodwork within the past year; last gynecologic appointment in January 2025.

Substance Use  
- Alcohol: Approximately once monthly (social, one drink typical – White Claw).  
- Caffeine: 100mg caffeine pill daily.  
- Nicotine/Cannabis/Other: Denied.

─────────────────────────────────────────────  
 Review of Systems (ROS)  
- Sleep: Difficulty falling asleep over the past one to two weeks due to anxiety and racing heart.  
- Appetite: Decreased over the past month; patient consumes approximately 1,200 calories per day.  
- Energy: Adequate for work though motivation for exercise is decreased.  
- Constitutional: Denies other significant changes.

─────────────────────────────────────────────  
 Physical Examination  
 Mental Status Examination  
- Appearance: Attended in person (no formal documentation available).  
- Behavior: Cooperative and engaged during the interview.  
- Speech: Normal rate and rhythm.  
- Mood: Initially described as “okay,” later reported depressive symptoms rated at 8/10 over the past week.  
- Affect: Appropriate to the content of the discussion.  
- Thought Process: Linear, logical, and goal-directed.  
- Thought Content: Endorses passive suicidal ideation (hopeless thoughts) without any plan or intent; reports negative self-talk and feelings of worthlessness/guilt related to her parents.  
- Perceptions: Denies hallucinations and paranoia.  
- Cognition: Alert and oriented; history is coherent.  
- Insight and Judgment: Fair; recognizes symptoms and seeks treatment; identifies her brother as a supportive contact.

Vital Signs / Physical Measurements  
- Height: 5'2" (self-reported)  
- Weight: Approximately 107 pounds (self-reported)

─────────────────────────────────────────────  
 Assessment / Diagnosis  
Anne Zheng is a female patient with ongoing issues of anxiety, depression, and a history of bulimia (currently in remission). Key points include her increased nightly anxiety and depressive symptoms, decreased motivation for activities other than work, passive suicidal ideation (without a specific plan), and the possibility of premenstrual dysphoric disorder (PMDD) due to cyclical mood changes.  
Diagnostic List:  
1. Generalized Anxiety Disorder  
2. Major Depressive Disorder, Recurrent  
3. Social Anxiety Disorder (performance type)  
4. Possible Premenstrual Dysphoric Disorder (PMDD) – to be monitored through mood tracking  
5. Bulimia Nervosa, in Remission  
6. Initial Insomnia Secondary to Anxiety

─────────────────────────────────────────────  
 Plan / Treatment

Medications  
1. Propranolol 10mg:  
   - Refill provided.  
   - Patient educated that it is non-habit forming and can be taken preventatively.  
   - Advised to take at 7–8 PM nightly when anxiety is elevated rather than waiting for symptoms to begin (noting a 1–2 hour onset of action).

2. Sertraline (Zoloft) 25mg:  
   - New prescription initiated for a trial of luteal phase dosing aimed at addressing possible PMDD.  
   - Instructions: Take one 25mg tablet daily starting two weeks prior to the expected period, and continue until the period begins. If the period is delayed, continue until onset.  
   - Recommendation: Take after dinner to reduce gastrointestinal upset; if sleep is affected, consider morning administration.  
   - Side Effects Reviewed: Potential for stomach upset, headaches, and dry mouth; standard antidepressant warnings provided regarding suicide risk.

3. Hydroxyzine 10mg:  
   - New prescription for PRN (as needed) use for acute anxiety and sleep difficulties.  
   - Directions: Take 1–2 tablets as needed if propranolol is insufficient; patient informed it acts similarly to a stronger Benadryl and may cause drowsiness.

Patient Education and Lifestyle Recommendations  
- PMDD:  
  - Discussed the possibility of PMDD contributing to cyclical mood changes.  
  - Encouraged use of a period-tracking app (e.g., My Calendar) for mood monitoring.  
  - Reviewed treatment options including antidepressants and discussed implications regarding her non-hormonal copper IUD.

- Lifestyle and Diet:  
  - Provided education on Mediterranean diet principles—focusing on omega-3 fatty acids, healthy fats, probiotics, and fiber.  
  - Recommended a trial of magnesium glycinate 400mg at bedtime to support sleep and reduce anxiety (provider to send a link for a reputable brand).  
  - Encouraged daily non-strenuous exercise (20–30 minutes of walking), particularly during periods of low motivation.

- Eating Disorder Monitoring:  
  - Emphasized the importance of adequate caloric intake and balanced nutrition for energy, cognition, and mood regulation.  
  - Advised that any escalation in body image concerns or calorie obsession should be discussed promptly.

Referrals/Recommendations  
- Gynecologic Care:  
  - Recommendation to establish care with a gynecologist, noting that Rush and UIC have PMDD specialists.

- Primary Care:  
  - Advised patient to establish or maintain care with her primary care physician.

Safety Measures  
- Patient denies active suicidal plan or intent; reports only passive suicidal ideation.  
- Identified her brother as a primary support for safety if symptoms worsen.  
- Instructed to contact the provider immediately if suicidal thoughts escalate.

Follow-Up  
- Scheduled to return in approximately 6 weeks to evaluate response to sertraline luteal phase dosing (allowing for one full menstrual cycle on medication).  
- Patient instructed to call and schedule the follow-up appointment.  
- Prescriptions have been sent to Walgreens on Halsted (expected turnaround: 20-30 minutes).

─────────────────────────────────────────────  
 Additional Documentation  
- Informed Consent & Risk Assessment:  
  - The patient was informed about the risks and benefits of new medications including standard antidepressant warnings regarding suicidal ideation.  
  - Safety was assessed through evaluation of passive suicidal ideation with no current plan; appropriate safety contacts were identified.

- Signature/Date:  
  - Documentation completed by Megan Becker on 07/31/2025.

─────────────────────────────────────────────  
 Quality Grade  
Grade: High Quality

─────────────────────────────────────────────  
 Additional Questions for Improvement  
- Are any additional details regarding the physical examination (e.g., other neurological or cardiovascular findings) required?  
- Is further clarification needed for the follow-up plan, such as specifying appointment time or modality?

Please advise if any further modifications or additional details are required.

Formatting

★★★★★5/5

The clinical note is comprehensive and well-organized. It includes detailed patient information, a clear chief complaint, an extensive HPI, thorough past medical history (with psychiatric, medical, and substance use details), a complete review of systems, and a detailed physical exam including a mental status exam. The assessment is well-documented with an appropriate diagnostic list, and the treatment plan is clearly outlined with medication details, patient education, safety measures, and follow-up instructions. These details provide ample information for medical coding, billing, and claims processing.

Queries

Could you please provide your formal credentials (MD, DO, NP, PA, etc.) for documentation purposes? This is important for billing and compliance.

Can you clarify the follow-up plan details, specifically whether the follow-up appointment will be in-person or telehealth, and if there are any specific time instructions available? This will help in accurately applying CPT codes for follow-up visits.

The current note only provides instructions regarding the addition of procedure codes for wounds but does not contain any clinical details about the actual wound treatments performed during this encounter. Could you please provide additional details regarding each wound? Specifically: Were any procedures (e.g., debridement, dressing change, closure, etc.) documented and performed on the wound(s)? What are the measurements or characteristics of each wound (to determine base codes and potential add-on codes)? Also, please confirm if an evaluation and management (E&M) service was provided during this visit. This information is required to assign the correct CPT codes [e.g., wound debridement codes, E&M codes].

Regarding the patient's appearance, could you provide any observations made during the Mental Status Examination? The appearance is noted as not formally documented in the transcript, which is an important aspect of the evaluation.

Could you provide any additional details in the physical exam section, such as neurological or cardiovascular exam findings, to further support the documentation for coding purposes (e.g., if there are any abnormal findings that might require codes like ICD R00 series for cardiovascular irregularities)?

Can you confirm the total duration of the visit for the E/M coding requirements? Explicit times are crucial for accurate coding.

Primary Diagnosis

90% Confidence

F41.1 ICD-10-CM i

The patient’s chief complaint of increased anxiety and difficulty falling asleep, along with her history of using propranolol for anxiety, supports a primary diagnosis of Generalized Anxiety Disorder (F41.1). This code is chosen based on the HPI and chief complaint description.

Other Diagnosis

80% Confidence

F40.10 ICD-10-CM i

The patient describes anxiety in performance/social situations for which she uses propranolol preemptively. This presentation is consistent with Social Anxiety Disorder (performance type) and F40.10 is used for social phobia without specification.

85% Confidence

F50.2 ICD-10-CM i

The patient has a history of bulimia nervosa, currently in remission. Although not actively symptomatic during this visit, her past diagnosis is noted in the assessment. F50.2 is used for Bulimia Nervosa.

75% Confidence

F32.81 ICD-10-CM i

The possibility of premenstrual dysphoric disorder (PMDD) is considered given the reported cyclical mood changes and the context of her menstrual cycle. F32.81 is used for PMDD.

85% Confidence

F33.1 ICD-10-CM i

The patient's report of depressive symptoms (rated 8/10 recently compared to her baseline of 2/10) and long-standing history supports a diagnosis of Major Depressive Disorder, Recurrent. The code F33.1 corresponds to a moderate recurrent depressive episode.

80% Confidence

G47.00 ICD-10-CM i

The patient reports initial insomnia characterized by difficulty falling asleep secondary to anxiety. G47.00 (Insomnia, unspecified) is used for this presentation.

Procedures

95% Confidence

90792 CPT i

The evaluation performed during this new patient visit, including assessment of psychiatric symptoms and initiation/modification of medication regimen (refills and new prescriptions), corresponds to CPT 90792.

Performed By Megan Becker
Modifier Value

Performed On 07/31/2025
Units Or Days 1

Schedule Unknown

Reason New patient psychiatric evaluation with medication management.

Payer Rules Evaluation

The payer rules described pertain exclusively to endovenous ablation and ultrasound-guided foam sclerotherapy procedures for symptomatic lower-extremity chronic venous insufficiency/varicose veins. The submitted procedure code 90792 (psychiatric diagnostic evaluation) is not covered under these criteria. There is no mapping between 90792 and any diagnosis codes listed (F41.1, F33.1, F40.10, F32.81, F50.2, G47.00) that would meet the specified criteria for varicose veins treatment. Additionally, the required clinical documentation, imaging, and conservative treatment duration for varicose veins procedures are absent. Prior authorization verification is also not applicable here. Therefore, based solely on the provided payer rules, this procedure does not comply with the coverage indications outlined.