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Clinical Note Reformatted

1. Patient Information
- Patient Name: Adam Wallace  
- Age: 26 years old  
- Gender: Male  
- Date of Service: April 21, 2025  
- Provider: Juliette Murphy  
- Specialty Code: 394800008  
- Place of Service: 11 (Office)  
- Visit Type: Established Patient  
- Telehealth: No

2. Chief Complaint
Follow-up for medication management of depression, anxiety, and PTSD symptoms. Patient also requested discussion regarding clonazepam for upcoming travel anxiety.

3. History of Present Illness (HPI)
This is a follow-up appointment for a 26-year-old male who was last seen on February 3, 2025. He has a history of mood disorder, anxiety, and PTSD. The following details are noted:

- Depression:  
  - Describes mood as “a little better” with less apathy and a reduction in feeling “flat.”  
  - Reports increased enjoyment in activities and engagement in his marriage.
  - Continues to have passive suicidal ideation (fleeting thoughts, no intent/plan) with less frequent occurrence than previously.

- Anxiety:  
  - Generalized day-to-day anxiety is manageable but exacerbated in crowds and trauma-related scenarios (e.g., bright lights, loud noises, smells, truck brakes).  
  - Experiences racing thoughts, ruminations, and catastrophizing with infrequent panic attacks (0–1 per week).

- PTSD Symptoms:  
  - Experiencing nightmares as flashbacks, occasional daytime flashbacks triggered by sensory cues, hypervigilance, an exaggerated startle response, and episodes of dissociation (couple times per week).

- Sleep:  
  - Improved sleep quality after transitioning to a new CPAP machine with a nightly duration of approximately 6–8 hours.  
  - Continues trazodone 50 mg at bedtime with a planned trial of 75 mg dose due to improved CPAP tolerance.

- Medication Update:  
  - Aripiprazole dose has been doubled by patient (taking 4 mg instead of 2 mg) with reported benefit.  
  - Sertraline has been maintained at 100 mg daily.

- Occupational/Functional Status:  
  - Difficulty with work concentration and sustainability of current job; seeking VA vocational rehabilitation.  
  - Appetite remains “okay” but with noted poor snack choices.  
  - Engages in daily exercise (walking his dog 2–3 times per day).

- Additional Concerns:  
  - Patient is planning a two-week trip for the end of August and requests a trial of clonazepam 0.5 mg for travel anxiety, particularly for use during the cruise component where marijuana is restricted.

4. Past Medical History (PMH)
- Major Depressive Disorder  
- Post-Traumatic Stress Disorder (PTSD)  
- Generalized Anxiety Disorder  
- Obstructive Sleep Apnea (improved with new CPAP machine)  
- Prediabetes

5. Review of Systems (ROS)
- Psychiatric: Depression, anxiety, PTSD symptoms (mood improvement, passive suicidal ideation, hypervigilance, flashbacks)  
- Sleep: Improved quality; CPAP compliance noted  
- Neurological/Cognitive: Reports difficulty concentrating at work; alert and oriented  
- Cardiovascular/General: No specific complaints noted  
- Substance Use: Occasional soda and energy drinks, rare alcohol use, marijuana used for pain and anxiety; no cigarette use

6. Physical Examination
Note: The following Mental Status Examination (MSE) is documented as part of the physical exam.

- Appearance: Patient attended in person; no formal documentation of appearance  
- Behavior: Cooperative and engaged  
- Speech: Normal rate and rhythm  
- Mood: Reported as “a little better” than last visit  
- Affect: Appropriate; able to discuss concerns openly  
- Thought Process: Logical and goal-directed  
- Thought Content: Presence of passive suicidal ideation (fleeting thoughts with no intent or plan); persistent morbid thoughts of escape; denies homicidal ideation  
- Perceptions: No auditory or visual hallucinations  
- Cognition: Alert and oriented; concentration difficulties noted in work settings  
- Insight: Good; aware of symptoms with active engagement in treatment  
- Judgment: Good; actively seeking help and engaged in therapy

7. Assessment / Diagnosis
1. Major Depressive Disorder  
   - Mild improvement noted (less apathy, improved engagement); passive suicidal ideation persists in a fleeting manner.

2. Post-Traumatic Stress Disorder (PTSD)  
   - Persistent symptoms including nightmares/flashbacks, hypervigilance, exaggerated startle, and episodes of dissociation.

3. Generalized Anxiety Disorder  
   - Day-to-day anxiety manageable; significant exacerbation in trauma-related or crowded settings with moderate ruminations and infrequent panic attacks.

4. Obstructive Sleep Apnea  
   - Improved sleep quality with the use of a new CPAP machine.

5. Prediabetes  
   - Ongoing; no recent changes reported.

8. Plan / Treatment

Medications
- Aripiprazole:  
  - Transition from 2 mg (actual use: 4 mg by doubling tablets) to a 5 mg tablet as 4 mg is not commercially available.  
  - Continue morning dosing.  
  - Patient to finish remaining 2 mg supply before switching to the 5 mg tablets.

- Trazodone:  
  - Continue 50 mg at bedtime.  
  - Patient may trial an increased dose of 75 mg given improved CPAP tolerance.  
  - VA provides refills; no separate prescription needed.

- Sertraline 100 mg:  
  - Continue current dose; will reassess in the fall if seasonal mood changes occur.  
  - VA provides refills; no separate prescription needed.

- Clonazepam 0.5 mg: (New Prescription for Travel Anxiety)  
  - Dispense: 30 tablets  
  - Directions: Take 1–2 tablets by mouth as needed for travel anxiety; do not exceed 2 tablets per day with at least 8 hours between doses.  
  - Prescription sent to CVS in Target on Sycamore Road.

Patient Education (Regarding Clonazepam)
- Onset of action: 30–60 minutes; duration: ~8 hours.  
- Avoid combining with alcohol, marijuana, or opioid/narcotic medications to prevent respiratory depression, impaired motor function, or confusion.  
- Do not drive until the effects are known (wait 3–4 hours after the initial dose).  
- First dose should be taken in a safe environment without the need to drive or leave immediately; avoid taking at bedtime for the first trial.  
- This is for short-term, as-needed use only; long-term use risks tolerance, dependence, and potential worsening of sleep, mood, and anxiety.

Lifestyle Recommendations
- Reduce soda and energy drink consumption; consider alternative beverages like flavored water or lower-caffeine drinks.  
- Increase physical activity with warmer weather.  
- Maintain healthy snack choices to counteract excessive intake of high-salt, high-sugar, and high-carbohydrate foods.

Therapy
- Continue ongoing therapy sessions with Christie.

Safety
- Patient denies any active suicidal ideation with intent or plan.
- Continued engagement in treatment, strong social support (marriage, therapy), and active participation in vocational rehabilitation serve as protective factors.

Follow-Up
- Next appointment scheduled for Monday, July 14, 2025, at 5:30 PM to reassess symptoms, review medication tolerability, and prepare for the upcoming trip.
- Instructed to contact the office if concerns arise before the scheduled follow-up.

Prescriptions Sent
- Aripiprazole 5 mg: Sent to CVS (Target, Sycamore Road)  
- Clonazepam 0.5 mg (30): Sent to CVS (Target, Sycamore Road)

9. Additional Documentation
- Informed Consent: Discussed and obtained verbally regarding medication changes and reasoning.  
- Risk Assessment: Passive suicidal ideation noted but with no current intent or plan; patient demonstrates adequate safety and insight.  
- Signature/Date:  
  - Provider: Juliette Murphy  
  - Date: April 21, 2025

Quality Grade: A

Additional Questions for Improvement:
1. Would any further details regarding the onset or triggers of previous episodes enhance the timeline in the HPI?  
2. Are there any recent laboratory or imaging studies that should be integrated into the documentation?  
3. Should any additional follow-up on therapy outcomes be scheduled beyond the next appointment?

Please advise if further modifications or additional details are needed.

Formatting

★★★★★5/5

The clinical note is comprehensive and detailed, including clear patient demographics, history of present illness with specific symptomatology for depression, anxiety, and PTSD, a thorough review of systems, and a detailed medication and treatment plan. Each section necessary for accurate coding and billing (e.g., HPI, ROS, physical exam, assessment/diagnosis, and plan) is well-documented.

Queries

Was an Evaluation and Management (E&M) service performed during this visit? If so, please specify the level of service provided to ensure that the appropriate CPT E&M code is added.

Could you please confirm if there have been any laboratory or imaging studies recently performed that relate to the patient’s conditions (e.g., blood tests for prediabetes)? This detail is important for codes like 250.xx for diabetes-related issues and may impact overall treatment documentation.

The instructions mention that procedure codes need to be added for each wound treated during this encounter. Could you please confirm if any wounds were actually treated during this visit? We need this clarification in order to assign wound-specific procedure codes (for example, codes for debridement, repair, or other wound care procedures).

Were any specific treatments or measurements taken for the wounds (e.g., length, width, depth) that would allow us to determine base codes and add-on codes? This detail is essential to identify the CPT procedure codes accurately.

Would you be able to provide more detailed information about the onset or triggers of the patient’s previous episodes of mood and anxiety symptoms, if available? This could help in refining the timeline elements for codes relating to mood disorders and anxiety.

Primary Diagnosis

95% Confidence

F33.41 ICD-10-CM i

The primary diagnosis is Major Depressive Disorder as identified by the chief complaint for follow‐up medication management. The note details improved mood with persistent passive suicidal ideation. F33.41 (Major depressive disorder, recurrent, mild, with suicidal ideation) is selected given the recurrent nature and the presence of passive suicidal ideation.

Other Diagnosis

95% Confidence

F41.1 ICD-10-CM i

Generalized Anxiety Disorder is reported as day-to-day anxiety that is exacerbated in specific scenarios. F41.1 (Generalized anxiety disorder) accurately reflects this condition.

95% Confidence

F43.12 ICD-10-CM i

PTSD is documented with recurrent nightmares, flashbacks, hypervigilance, exaggerated startle, and episodes of dissociation. F43.12 (Post-traumatic stress disorder with dissociative symptoms) is the most specific code capturing these features.

95% Confidence

G47.33 ICD-10-CM i

Obstructive Sleep Apnea, which is noted to have improved with the new CPAP machine, is captured by G47.33.

95% Confidence

R73.03 ICD-10-CM i

Prediabetes is listed in the patient’s past medical history with no change noted, and R73.03 (Prediabetes) is used to capture this condition.

Procedures

Payer Rules Evaluation

The current claim documentation pertains to mental health treatment and medication management with no procedure codes related to varicose vein treatments (e.g., endovenous ablation or ultrasound‐guided foam sclerotherapy) as defined in the payer rules. The payer rules require procedures for symptomatic lower-extremity chronic venous insufficiency with detailed documentation including imaging, CEAP classification, and conservative therapy compliance. In this submission, no procedure codes are provided and the diagnostic codes (F33.41, F43.12, F41.1, G47.33, R73.03) do not align with the covered venous conditions. Additionally, necessary prior authorization documentation, modifier usage, and place-of-service information relevant to varicose vein procedures are not addressed. As a result, mapping procedure codes to diagnosis codes is not applicable under the provided coverage criteria. This situation needs clarification concerning the intended procedure and its documentation.