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Clario - AI Agent for Medical Coding v1.1

Below is the reformatted clinical note based strictly on the provided information:

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 Patient Information
- Provider: Juliette Murphy  
- Specialty: 394800008  
- Date of Service: August 15, 2025  
- Place of Service: Office (11)  
- Visit Type: Established Patient  
- Telehealth: No  
- Patient Age: 26 years old  
- Patient Gender: Male

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 Chief Complaint
Patient presents for psychiatric medication management follow-up. (Last seen in March 2025)

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 History of Present Illness (HPI)
- Narrative:  
  The patient reports an overall "status quo" with a day-to-day fluctuating mood. He describes feeling generally stable when he is “in control of his own thoughts” and maintains a positive outlook. However, as the day progresses—with phone calls, reminders from his girlfriend regarding tasks, and daily stressors—he experiences waves of low mood, irritability, and apathy of mild to moderate severity that are situational in nature. He denies suicidal ideation.
  
- Sleep:  
  Reports variable sleep quality; uses a CPAP machine. Some nights he sleeps well while other nights he struggles to fall or stay asleep. He notes a correlation between stress levels and sleep quality. Previously, he used hydroxyzine 25mg PRN for sleep with good effect but has finished that prescription and is requesting a refill.
  
- Anxiety:  
  Notices increased anxious feelings and is actively working on reframing negative thoughts. Denies panic attacks and reports improved coping skills.
  
- ADHD Symptoms:  
  Currently taking Adderall XR 25mg in the morning (around 6:00-6:30 AM). He experiences benefits in focus, attention, and mood stability during the effective window but notes a decline in effect around 2:00 PM with a “crash” by 4:30 PM. He previously benefited from an immediate-release (IR) booster dose in the afternoon.
  
- Appetite:  
  Reports decreased appetite (unchanged from previous visits) and late-night cravings for sweets.
  
- Additional Narrative Details:  
  The patient is facing significant financial stress, legal and custody issues following a recent divorce, and has recently started therapy with a new therapist (Mike Lewis, PsyD). He also has plans for initiating a home workout routine once his son Arlo starts school. He is aware of upcoming changes, including a physical examination with lab work scheduled for August 27, 2025.

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 Past Medical History (PMH)
- Psychiatric History:  
  - Medication management for ADHD, anxiety, and depressive symptoms  
  - Previous trials:  
    - Sertraline (up to 100mg)  
    - Fluoxetine (discontinued due to fatigue)  
    - Bupropion (Wellbutrin) was prescribed but never started  
- Note: No additional past medical conditions are documented in this note.

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 Review of Systems (ROS)
- General: Reports stress related to life circumstances (divorce, financial stress).
- Psychiatric:  
  - Mood: Fluctuating, situational low mood  
  - Anxiety: Increased awareness of anxious feelings with effective coping strategies  
  - Sleep: Variable quality; difficulty with sleep onset and maintenance on stressful nights, uses CPAP  
  - ADHD: Symptoms managed during morning hours with medication, wearing off later in the day  
- Appetite: Decreased with late-night sweet cravings

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 Physical Examination
- Vital Signs:  
  - Blood pressure noted during a recent pediatric appointment for his son was described as “on the higher end of good” (if 10 points higher, it would be in the slightly elevated range).
  
- Mental Status Examination:  
  - Appearance: Not documented  
  - Behavior: Cooperative and engaged  
  - Speech: Normal rate, rhythm, and volume  
  - Mood: Described as “okay” with day-to-day variability  
  - Affect: Appropriate and congruent  
  - Thought Process: Linear and goal-directed  
  - Thought Content: No suicidal or homicidal ideation  
  - Perception: No abnormalities noted  
  - Cognition: Alert and oriented  
  - Insight/Judgment: Good – patient is aware of symptoms, engaged in treatment planning, and receptive to recommendations

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 Assessment / Diagnosis
1. Attention-Deficit/Hyperactivity Disorder (ADHD):  
   - Partially controlled on current regimen with Adderall XR 25mg in the morning; however, the effect diminishes by mid-to-late afternoon. History of benefit from an IR booster dose.
  
2. Generalized Anxiety Disorder:  
   - Mild, situational symptoms that are managed with cognitive coping strategies; no panic attacks reported and no daily anxiety medication currently required.
  
3. Depressive Symptoms:  
   - Mild and situational in nature, likely related to ongoing financial stressors and life changes. No suicidal ideation.
  
4. Insomnia, Intermittent:  
   - Variable sleep quality despite CPAP use; previously responsive to PRN hydroxyzine 25mg without next-day grogginess.

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 Plan / Treatment
- Medications:  
  1. Adderall XR 25mg:  
     - Continue current regimen (one tablet daily in the morning).  
     - Refill to be sent to pharmacy; fillable on 9/6/25.  
     - Patient to call the pharmacy to fill when ready.
  
  2. Adderall IR 15mg:  
     - Resume as an afternoon booster dose.  
     - New prescription sent to Walgreens on State Street, Geneva.
  
  3. Hydroxyzine 25mg:  
     - Refill for PRN use for sleep on nights with consecutive poor sleep.  
     - Prescription sent to Walgreens on State Street, Geneva.
  
- Counseling/Education:  
  - Discussed the high sodium content in LMNT electrolyte drinks due to borderline blood pressure and concurrent stimulant use; advised monitoring sodium intake from other sources.
  - Discussed potential future anxiety medication options including Buspirone (with 2-3x daily dosing) and Lexapro (effective for anxiety at lower doses, also aiding mood).
  - Encouraged initiation of a home workout routine as planned.
  - Requested that the patient share the upcoming bloodwork results from his full physical exam on 8/27/25.
  - Discussed recommended labs including CMP, CBC, thyroid, B12, vitamin D, A1C, and testosterone.
  
- Coordination of Care:  
  - Patient signed a release of information for communication with his new therapist, Mike Lewis, PsyD, in Naperville.  
  - Plan to coordinate medication management with his therapist as needed.  
  - Patient to update the provider on any recommendations from the therapist at the next visit.
  
- Follow-Up:  
  - Next appointment scheduled for Friday, September 12, 2025 at 10:30 AM.  
  - Patient to relay today’s discussion to the new therapist.  
  - Consideration to discuss initiation of an anxiety medication pending therapist input.

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 Additional Documentation
- Informed Consent / Risk Assessment:  
  - Informed consent for treatment was obtained (documentation of the signed release for therapist communication is noted).  
  - Risk assessment regarding mood fluctuations and medication management was addressed during the visit.
  
- Signature / Date:  
  - (Electronic signature/documentation as per standard protocol; specific signature and date details are not provided in the note.)

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 Quality Grade
Quality Grade: High

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 Additional Questions for Improvement
1. Would additional clarification regarding the duration and frequency of mood fluctuations further enhance the HPI?
2. Are there any documented past medical conditions or additional psychiatric history details (beyond medication trials) that should be integrated into the PMH section?
3. Should explicit vital sign values (e.g., exact blood pressure reading) be recorded for future visits to better quantify changes?

Formatting

★★★★★5/5

The clinical note is highly detailed and complete, including comprehensive patient demographics, chief complaint, a thorough HPI with multiple symptom domains (mood fluctuations, sleep issues, anxiety, ADHD medication effects), detailed past medical and psychiatric history, a well-organized review of systems, physical examination components (even though some specifics are noted as not documented), clear assessment with diagnoses, and a detailed plan with medication management, lab orders, and follow-up instructions. This level of detail facilitates coding, billing, and claims processing.

Queries

Can you provide more detail regarding the duration and frequency of the patient's mood fluctuations, as additional quantification of these symptoms (e.g., how long the low mood lasts, frequency per day/week) could be useful for a more precise coding of depressive symptoms or adjustment disorder?

Could you please provide details regarding the patient's appearance during the Mental Status Examination? This information is important for a complete assessment of the patient's condition.

Could you clarify if the patient is currently experiencing any side effects from the medications prescribed? Specific information on medication tolerability would be helpful for ongoing management and documentation.

Could you please clarify the physical examination findings further? Specifically, while the mental status exam is thorough, the general appearance and complete vital signs (e.g., exact blood pressure, pulse, temperature) are not fully documented. Including these details would improve the documentation for coding related to physical exam components [e.g., CPT codes for consultation/physical exam].

Regarding the depressive symptoms, could you clarify if these symptoms meet the full diagnostic criteria for a depressive disorder (e.g., Major Depressive Disorder, mild) or if they are solely situational without meeting full criteria? This will determine whether a code like F32.0 (Major depressive disorder, single episode, mild) is appropriate or if an alternative such as an adjustment disorder code should be used.

The provided note appears to be a set of instructions for coding procedures per wound, rather than actual clinical encounter details. Could you please clarify and provide the clinical details for this encounter? Specifically: (a) How many wounds were treated? (b) What procedures (if any) were performed on each wound along with the measurements (base codes and add-on codes) for each? (c) Were there any E&M services provided during the visit? This information is necessary to accurately assign ICD codes, CPT codes (including wound treatment procedures and E&M policies), and any other appropriate codes. (For example, codes related to wound debridement or wound closure might be applicable if treatment details are provided.)

For the ADHD diagnosis, can you please confirm if adult ADHD should be coded as F90.9 (Attention-deficit hyperactivity disorder, unspecified) or if there is more specific guidance (such as predominantly inattentive type) that would require a different code? This clarification will help ensure the most specific ICD-10 code is used [proposed ICD Code: F90.9].

Primary Diagnosis

95% Confidence

F90.9 ICD-10-CM i

The patient presents for psychiatric medication management with specific issues related to ADHD. The note documents partial control of ADHD with Adderall XR in the morning and diminishing effect later in the day, establishing ADHD as the primary concern for this visit. F90.9 is used here for adult ADHD when further specification is not provided.

Other Diagnosis

95% Confidence

G47.00 ICD-10-CM i

The note documents intermittent insomnia with variable sleep quality despite CPAP use. G47.00 (Insomnia, unspecified) is selected to reflect the patient's sleep difficulties.

95% Confidence

F41.1 ICD-10-CM i

The patient reports increased anxious feelings, which are situational and managed with coping strategies. The documentation supports a diagnosis of Generalized Anxiety Disorder, coded as F41.1.

85% Confidence

F32.0 ICD-10-CM i

The patient exhibits mild, situational depressive symptoms likely related to ongoing stressors. F32.0 (Major depressive disorder, single episode, mild) is provisionally selected pending further clarification on whether full diagnostic criteria are met.

Procedures

Payer Rules Evaluation

The provided payer rules strictly pertain to endovenous ablation and ultrasound‐guided foam sclerotherapy for symptomatic lower-extremity CVI/varicose veins, requiring documentation of specific clinical findings, imaging, CEAP classification, and prior conservative therapy. The clinical note, however, involves psychiatric medication management for ADHD, anxiety, and depressive symptoms and does not include any procedure codes related to varicose vein treatment. No mapping of procedure codes to venous disease diagnosis codes is applicable. Additionally, there is no supporting documentation, imaging, or prior authorization for a CVI-related procedure as required by the rules. As the submitted clinical information does not address any elements of the venous ablation criteria, clarification is needed regarding whether a procedure related to CVI is being sought or if this is a separate claim for psychiatric management.