Dashboard

Origination

Clario - AI Agent for Medical Coding v1.1

Patient Information
- Name: Adrian Dalessandro  
- Age: 26 years old  
- Gender: Male  
- Provider: Amanda Lantow  
- Specialty: 394800008  
- Date of Service: April 10, 2025  
- Place of Service: Office (11)  
- Visit Type: Established Patient  
- Telehealth: No

Chief Complaint
Patient presents for psychiatric follow-up, requesting an increase in his depression medication and assistance with ADHD management.

History of Present Illness (HPI)
- Narrative:  
  The patient reports feeling generally good overall, although some days he experiences low motivation where he feels like staying in bed all day. He contrasts these days with others (including yesterday and today) when he has good energy and a drive to be active. The patient specifically requested an increase in his Prozac (fluoxetine) for better management of his depression. Additionally, he reports significant difficulties with focus and attention consistent with ADHD symptoms, such as frequently losing his phone and difficulty maintaining focus on tasks.
  
- Medication Adjustments for Sleep:  
  He takes olanzapine for sleep and has adjusted the timing (taking it around 6:30 PM so that he feels groggy by 8:00 PM and then wakes at 6:00 AM without residual sedation). The medication effect lasts about 12 hours. Previously, taking the olanzapine later resulted in morning residual sedation.

- Additional Details:  
  - Appetite: Variable; sometimes no appetite which later transitions into significant hunger, attributed to his busy schedule.  
  - Mood: Improvement noted by both the patient and his husband, who states the patient “seems like yourself.” He mentioned that previously he would "plan all day and spiral," but this has improved.  
  - Anxiety: Stable with no worsening, even with the new job responsibilities.  
  - ADHD Concerns:  
    - Frequent misplacement of personal items (e.g., phone lost “a hundred times a day”).  
    - Difficulties with maintaining focus on multiple tasks at work, getting overly focused on one task while neglecting others.  
    - Completed ADHD testing from Lighthouse, which showed results “not within normal limits” with a suggestion of possible attention deficit including ADHD.  
    - Has not been on any ADHD medications previously.

Past Medical History (PMH)
- Psychiatric History:  
  - Major Depressive Disorder (currently managed with fluoxetine and other supportive medications)  
  - Anxiety Disorder  
  - ADHD (recently evaluated externally by Lighthouse)  
  - Sleep disturbances/Insomnia (managed with olanzapine)

Review of Systems (ROS)
- General: Good energy on certain days; occasional low motivation.
- Psychiatric: Depression with occasional low energy; anxiety stable; ADHD symptoms as described.
- Sleep: Good sleep quality with medication (olanzapine) timing adjustments.
- Appetite: Variability noted with periods of no appetite followed by excessive hunger.

Physical Examination
- Mental Status Examination:  
  - Appearance: Patient present for in-person appointment  
  - Behavior: Engaged, cooperative, and communicative  
  - Speech: Normal rate, rhythm, and volume; coherent and goal-directed  
  - Mood: “Good” as reported by patient  
  - Affect: Appropriate and congruent with stated mood  
  - Thought Process: Organized and linear  
  - Thought Content: No suicidal or homicidal ideation expressed  
  - Cognition: Alert, oriented, and engaged throughout the conversation  
  - Insight/Judgment: Good; patient demonstrates an understanding of his conditions and actively participates in treatment decisions

- Records Reviewed:  
  - ADHD evaluation from Lighthouse indicating results “not within normal limits” and suggestive of an attention deficit warranting treatment.

Assessment / Diagnosis
1. Major Depressive Disorder  
   - On low dose fluoxetine 20 mg with some residual symptoms (e.g., occasional low motivation and desire to remain in bed). Overall improvement noted both by the patient and collateral history from his husband.
   
2. Attention Deficit Hyperactivity Disorder (ADHD)  
   - Confirmed by external evaluation from Lighthouse. Symptoms include difficulties with focus, frequently losing personal items, and trouble managing multiple tasks at work. Likely inattentive type with possible hyperactive elements. Patient has not received ADHD medication previously.
   
3. Anxiety Disorder  
   - Stable and well-controlled on the current medication regimen despite new work-related stressors.
   
4. Sleep Disorder/Insomnia  
   - Well-managed using olanzapine with current timing adjustments leading to minimized morning sedation.

Plan / Treatment
Medication Changes:
- Fluoxetine:  
  - Increase dose from 20 mg to 40 mg daily for improved depression management.  
  - Patient may use two 20 mg tablets or obtain a new prescription for 40 mg capsules.  
  - Pharmacy: Walgreens on South Elpine.
  
- Atomoxetine (Strattera) 25 mg:  
  - New initiation for ADHD management at a low dose considering potential interaction with fluoxetine (which can increase blood levels of atomoxetine).  
  - Counseling Provided:  
    - Advised to monitor for gastrointestinal upset, decreased appetite, rapid heart rate, and sensations of increased blood pressure.  
    - Patient instructed to discontinue atomoxetine and contact the office immediately if significant side effects occur.

Medications Continued:
- Olanzapine: Continue current dose and adjusted timing (6:30 PM administration).
- Buspirone: Continue as current.
- Lamotrigine: Continue with 90-day supply plus available refills.

Patient Education:
- Detailed explanation of the mechanism of atomoxetine as a non-stimulant ADHD medication.
- Reviewed rationale for initiating a non-stimulant treatment (first-line approach due to ease of access, cost, and safety profile).
- Discussed potential side effects including gastrointestinal upset, appetite suppression, and cardiovascular effects (tachycardia, increased blood pressure).
- Instructed to immediately contact provider if he experiences significant adverse effects after starting atomoxetine.

Follow-up:
- Scheduled return appointment for May 8, 2025 at 4:30 PM (approximately 1 month) to assess response to the new medication regimen, particularly the atomoxetine.
- Advised to call earlier if any concerns arise prior to the scheduled appointment.

Additional Documentation
- Informed Consent: Discussed and obtained for medication changes.
- Risk Assessment: No acute risk of harm noted during this visit.
- Signature & Date:  
  Amanda Lantow, MD – April 10, 2025

Quality Grade: A

Questions for Improvement:  
1. Would additional details on past medical history, such as previous psychiatric hospitalizations or other medical conditions, be available to further enhance the documentation?  
2. Is there a need to include any vital signs or physical exam findings beyond the mental status exam for a more comprehensive note?

Formatting

★★★★★5/5

The clinical note is comprehensive and detailed. It includes key components such as patient demographics, chief complaint, HPI with medication adjustments and symptoms, past medical history, review of systems, a thorough mental status examination, assessment with clear diagnostic impressions, and a detailed treatment plan with follow-up instructions. This level of detail facilitates accurate coding, billing, and claims processing.

Queries

For the anxiety disorder, can you specify if this is Generalized Anxiety Disorder (suggesting F41.1) or another type? This will allow us to assign the most specific diagnosis code.

Can you please clarify if the patient’s history of depression represents a recurrent episode (which would support using F33.1 for Major Depressive Disorder, recurrent, moderate) or a single episode? This clarification is important to ensure the most specific ICD code is used.

Are there additional details regarding the patient’s past psychiatric hospitalizations or any other co-morbid medical conditions not mentioned? This information can be useful for more detailed coding and risk stratification (e.g., ICD-10 codes for MDD, ADHD, and anxiety disorders).

Regarding the ADHD diagnosis, do you have confirmation on whether the presentation is predominantly inattentive, combined, or another subtype? While F90.0 is generally used for ADHD, additional specificity might be available.

Could you provide any vital signs data (e.g., blood pressure, heart rate) documented during this visit? Including these details can help in further clinical correlation and coding for office visits (e.g., CPT codes for office/outpatient visits).

Primary Diagnosis

90% Confidence

F33.1 ICD-10-CM i

Major Depressive Disorder is the primary concern based on the chief complaint where the patient requested an increase in his fluoxetine dosage due to residual depressive symptoms. F33.1 (Major depressive disorder, recurrent, moderate) is chosen assuming the depressive episodes are recurrent.

Other Diagnosis

85% Confidence

F41.1 ICD-10-CM i

Anxiety disorder is included because the patient has an established diagnosis managed with buspirone and is noted to be stable. F41.1 (Generalized Anxiety Disorder) is applied, pending clarification if another anxiety subtype is confirmed.

85% Confidence

G47.00 ICD-10-CM i

Sleep disorder/insomnia is documented as being managed with olanzapine and timing adjustments. G47.00 (Insomnia, unspecified) is used to capture this condition.

90% Confidence

F90.0 ICD-10-CM i

ADHD is addressed as the patient reports significant inattention, misplacing items frequently, and difficulty managing tasks. F90.0 is used for Attention Deficit Hyperactivity Disorder.

Procedures

Payer Rules Evaluation

The provided encounter focuses on psychiatric management and medication adjustments for depression, ADHD, anxiety, and sleep disturbances. None of the procedures or services described relate to symptomatic lower-extremity chronic venous insufficiency/varicose veins ablation or ultrasound‐guided foam sclerotherapy, for which the payer rules apply. There is no mapping of any procedure code to the required varicose vein diagnosis codes (eg, I83.10–I83.129, etc.) or fulfillment of criteria A–D (symptoms, duplex imaging, CEAP classification, and conservative therapy) as defined in the rules. Additionally, none of the necessary documentation, prior authorization paperwork, or modifier details for varicose vein procedures are present. Since the current claim does not even address the covered condition and related interventions, the rules are not applicable here. Needs Clarification on whether any additional varicose vein treatment is intended.