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Reformatted Clinical Note

Patient Information
- Date of Service: 09/12/2025  
- Provider: Juliette Murphy  
- Specialty: 394800008  
- Place of Service: 02 (Telehealth)  
- Visit Type: Established Patient  
- Patient Gender: Male

Chief Complaint
Follow-up appointment for medication management of ADHD, depression, and anxiety.

History of Present Illness (HPI)
- Onset & Duration: Approximately one month since the previous appointment.  
- Narrative: The patient, an established male patient, reports his mood has been good overall despite a busy month filled with his children’s sports activities (softball and baseball).  
- ADHD Symptoms and Medication:  
  - Medication Regimen:  
    - Adderall XR 25mg daily in the morning (around 6 AM) with reported efficacy through early afternoon.  
    - Adderall IR used as an afternoon booster approximately 4-5 days per week as needed.  
  - Symptom Details:  
    - Days when the XR is inadequate are attributed to increased busyness, poor sleep, or higher stress levels.  
    - Occasionally, the patient feels it is too late (around 4 PM) to take the afternoon booster.  
    - Initially experienced difficulty obtaining the booster due to pharmacy ordering issues.  
  - Insurance: Not covering medications due to out-of-network provider; patient is using GoodRx.
- Depression/Anxiety:  
  - Mood: Mood is reported as "good" and "status quo"; mild depressed mood, sadness, and reduced enjoyment persist in the background.  
  - Therapy: The patient is working with a new therapist (Dr. Mike Lewis) biweekly.  
- Sleep:  
  - Medication & Effects: Uses hydroxyzine approximately 4 nights per week before bed. Sleep is reported as "pretty good" with deeper sleep noted when on hydroxyzine, although there is some morning grogginess.  
  - CPAP: Continues regular use.
- Recent Primary Care Visit (08/27/2025):  
  - Findings:  
    - Comprehensive blood work was within normal limits except for low testosterone (209) and low vitamin D3 levels.  
    - Blood pressure and cholesterol were within normal limits.  
  - Recommendations: Advised colonoscopy scheduling and exploration of natural supplements for testosterone support.

Past Medical History (PMH)
- Documented Conditions:  
  - ADHD  
  - Depression  
  - Anxiety  
- Additional Historical Details: Not further specified in the provided notes.

Review of Systems (ROS)
- General: No significant changes noted; overall feeling “good.”  
- Neurological/Psychiatric:  
  - ADHD well-managed with current regimen.  
  - Mild persistent depression and anxiety with no acute exacerbations.  
- Sleep: Reports good sleep quality with supportive measures (hydroxyzine and CPAP).  
- Endocrine: Low testosterone and vitamin D3 per recent primary care lab reports.  
- Other Systems: Not documented.

Physical Examination
- Telehealth Observation:  
  - Patient appeared on video and engaged appropriately in conversation.  
  - Minor technical difficulties resolved after re-signing into the session.
- Vital Signs:  
  - Blood pressure noted as "good" based on recent primary care evaluation (specific numbers not provided).
- OCD Assessment:  
  - Severity Band: Subclinical  
  - Total Score: 0/40 (Obsessions: 0/20, Compulsions: 0/20)
- Laboratory Results (from 08/27/2025):  
  - Testosterone: 209 (low)  
  - Vitamin D3: Low  
  - Cholesterol and other labs: Within normal limits

Assessment / Diagnosis
1. Attention-Deficit/Hyperactivity Disorder (ADHD):  
   - Stable on current medication regimen (Adderall XR with as-needed IR booster).  
   - Considerations based on patient’s report of activity levels and timing of medication doses.
2. Depression:  
   - Mild, stable.  
   - Current management includes biweekly therapy sessions and medication coordination.
3. Anxiety:  
   - Managed with hydroxyzine as needed.  
   - No acute exacerbation noted.
4. Sleep Disturbance:  
   - Improved with hydroxyzine and regular CPAP use.
5. Low Testosterone:  
   - Lab value of 209 noted; primary care provider provided educational materials regarding natural supplementation.
6. Vitamin D Deficiency:  
   - Recently initiated over-the-counter supplementation.

Plan / Treatment
1. ADHD/Medication Management:  
   - Continue Adderall XR 25mg daily in the morning.  
     - Prescriptions scheduled for refills approximately on October 3 and then at 28-day intervals (next refill in November).  
   - Continue Adderall IR as needed in the afternoon (4-5 days per week).  
     - Next fill to be sent with a refill date of November 29; patient to contact the pharmacy when ready.
2. Depression/Anxiety:  
   - Continue current management; defer any changes in medications.  
   - Maintain biweekly therapy with Dr. Mike Lewis.
3. Sleep:  
   - Continue hydroxyzine as needed (up to 2 tablets per day as previously prescribed) and adhere to CPAP use.
4. Supplements / Laboratory Follow-up:  
   - Continue vitamin D supplementation.  
   - Utilize educational materials regarding natural supplements for testosterone support.
5. Coordination of Care:  
   - Therapies are provided by separate clinicians; coordination remains in place.  
   - Follow up regarding recommendations from primary care (colonoscopy scheduling).
6. Follow-Up Appointment:  
   - Scheduled for December 12, 2025 at 11:00 AM (Telehealth).
7. Patient Instructions:  
   - Continue the current medication regimen as prescribed.  
   - Maintain regular CPAP use.  
   - Monitor symptoms and contact the provider should there be any worsening of depression or anxiety symptoms.  
   - Call the pharmacy when ready for Adderall refills.  
   - Consider changing to an in-network insurance plan in November if possible.

Additional Documentation
- Informed Consent / Risk Assessment: Not explicitly documented.  
- Patient Signature / Date: Not provided in the notes.

Quality Grade: High

Questions for Improvement
1. Would additional explicit documentation of past medical history or review of systems be beneficial for future visits?  
2. Should the total time of the visit and a clear provider credential be additionally documented for E/M billing purposes?  
3. Is there a need for further elaboration on the patient's social and family history in upcoming visits?

Formatting

★★★★★4/5

The clinical note is detailed and covers most necessary aspects for medical coding and billing, including HPI details, medication regimen, lab findings, and a clear treatment plan. However, there are gaps such as the absence of explicit documentation of patient/provider signatures, specific vital sign values (with only a general note that blood pressure is 'good'), and the total time spent during the visit which is important for E/M billing. Additionally, explicit informed consent is not documented.

Queries

The provided information does not include any specific clinical details regarding wound treatment (e.g., wound location, size, description, or specific procedure performed on the wound) or details about an E&M office visit. Could you please provide additional details on the following: (a) Were any wounds treated during this encounter? If yes, please provide information such as wound location, size/measurement, and the specific treatment or procedure performed so that the appropriate Base and Add-On CPT codes can be assigned. (b) Was an E&M office visit performed and, if so, what level of service (detail, comprehensive, etc.) was provided? This clarifies whether procedures (wound treatment and E&M) are billable as per [wound procedure codes and E&M CPT coding guidelines].

Could you please confirm if additional explicit documentation regarding the total time spent on the visit, detailed physical exam findings, or provider credential information should be included to support optimal E/M coding, particularly for CPT code 99214 (telehealth encounter)? This clarification helps ensure that modifier details and E/M level selection are accurately supported.

Could you provide specific vital sign measurements (e.g., blood pressure values) instead of a general description, to ensure precise documentation for E/M coding (for example, using code 99213 requirements)?

Can you clarify the provider's credentials and their role in this telehealth visit? Specifically, what are your qualifications or specialty beyond the coded specialty in the documentation? Including this information is important for clarity in billing and coding.

Would it be possible to include the total time spent on the visit or the level of complexity for E/M coding clarification (helpful for modifiers like 25 or 52)?

Could you please provide specific laboratory results, including blood pressure readings, instead of general statements such as 'good' or 'within normal limits'? This will facilitate proper coding and billing for the encounter. Specific BP numbers and lab values are crucial for assessing medical necessity and understanding the patient’s health status.

Could you please add explicit documentation of the patient and provider signatures and dates to meet compliance for billing purposes (e.g., CPT codes requiring signature verification)?

Could you clarify the provider's name and credentials? This is necessary to ensure accurate documentation for billing purposes.

The provided note does not include specific details about any wounds treated during the encounter, such as the number, size, location, or type of treatment (e.g., debridement, closure, irrigation, etc.). Could you please provide additional clinical details regarding each wound and the exact treatments performed? This information is necessary to assign the appropriate CPT codes for the procedures, including determining if add-on codes for wound measurements apply and if any E&M service was provided (for example, office visit code 99213 or similar based on the complexity). Please specify if any wounds were treated or if this encounter only involved evaluation with no billable wound treatment procedures.

Can you provide the specific vital signs numbers for this patient, including blood pressure readings? This information is essential for completeness in billing and coding (e.g. possible codes for hypertension).

Can you indicate the total duration of the telehealth visit? Documenting this time is vital for coding the E/M visit level accurately.

Primary Diagnosis

99% Confidence

F90.9 ICD-10-CM i

Attention-Deficit/Hyperactivity Disorder is the chief complaint for this medication management follow-up. The note details the current regimen (Adderall XR and as-needed IR booster) justifying F90.9 for adult ADHD.

Other Diagnosis

95% Confidence

E55.9 ICD-10-CM i

The patient’s lab work revealed low vitamin D3 levels, with E55.9 used to code for unspecified vitamin D deficiency.

95% Confidence

F32.0 ICD-10-CM i

Mild depression is noted in the assessment with stable mood and persistent low mood elements. F32.0 is used for a mild depressive episode.

95% Confidence

F41.9 ICD-10-CM i

The patient’s anxiety, which is managed with hydroxyzine and is mentioned in the assessment, is best represented by the unspecified anxiety disorder code F41.9.

90% Confidence

G47.00 ICD-10-CM i

Even though the patient reports good sleep quality, the assessment lists 'Sleep Disturbance' managed by hydroxyzine and CPAP. G47.00 is used for unspecified insomnia/sleep disturbance.

95% Confidence

E29.1 ICD-10-CM i

Low testosterone is noted from recent lab findings (value of 209). E29.1 (testicular hypofunction) matches the clinical evidence of decreased testosterone levels.

Procedures

Payer Rules Evaluation

The payer rules provided are specific to lower‐extremity varicose vein procedures (endovenous ablation and foam sclerotherapy) and require elements such as documented venous insufficiency symptoms, duplex imaging, CEAP classification, and a trial of conservative therapy. In this case, the clinical note is a follow-up for ADHD, depression, and anxiety without any mention of varicose veins, lower-extremity symptoms, or associated diagnostic studies. There are no procedure codes submitted that would correspond with the covered varicose vein interventions, and the associated diagnosis codes (F90.9, F32.0, F41.9, G47.00, E29.1, E55.9) do not match the payer’s covered ICD-10-CM examples related to venous insufficiency. As such, mapping of procedure codes to diagnosis codes is not applicable, and the required documentation (pre-procedure imaging, symptom duration, conservative therapy details, and prior authorization) is missing. Since the payer’s rules are not intended for or triggered by the current services, further clarification is needed regarding the intended procedure and appropriate routing according to the correct service guidelines.