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Clario - AI Agent for Medical Coding v1.1

Below is the reformatted clinical note using the standardized template:

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Patient Information

• Name: Addison Marx  
• Gender: Female  
• Provider: Amanda Lantow (Specialty Code: 394800008)  
• Date of Service: 10/07/2025  
• Place of Service: 02 – Telehealth  
• Visit Type: Established Patient

Chief Complaint

Medication follow-up for ADHD and anxiety management.

History of Present Illness (HPI)

The patient is an established female patient presenting via telehealth for psychiatric medication follow-up. She reports an overall improvement since her last visit with reduced anxiety and improved control of her thoughts. Key points include:

• Medication Effects:  
 – Currently taking immediate-release Adderall 10mg twice daily (morning and afternoon).  
 – Reports that dose increases yield good effect for approximately one week before waning.  
 – Denies difficulty with focus but notes feeling “a little sleepy still.”

• New Symptom:  
 – Increased itchiness and subsequent scalp picking leading to small red marks. This behavior is new since starting Adderall and the patient is working to stop it.

• Functional Impairment & School Performance:  
 – Reports doing well in school; a month off medication was described as “rough,” suggesting that the current regimen is effective.  
 – Example provided: Able to clean out the bathroom closet in about an hour without burnout, which is a marked improvement from prior experiences.

• Sleep:  
 – Working to correct sleep schedule.  
 – Notes that although she gets to bed at a better time now, it takes longer to fall asleep due to the new schedule and her historical poor sleep profile.

• Memory:  
 – Reports that memory is “getting better” and anticipates further improvement with consistent medication use and studying.

• History of Restless Legs:  
 – Long-standing history since postpartum trauma (“trauma postpartum when I was paralyzed”).  
 – Managed by taking evening doses shortly before bedtime; occasional difficulty returning to sleep if awakened.

Past Medical History (PMH)

• Not documented in the provided note.

Review of Systems (ROS)

• Neuropsychiatric:  
 – ADHD, anxiety symptoms, and new scalp itching/skin picking.  
 – Memory noted to be improving.  
• Sleep:  
 – Sleep disturbances; difficulty with sleep onset despite earlier bedtimes.  
• Neurological:  
 – History of restless legs since postpartum trauma.  
• No additional systems explicitly documented.

Physical Examination

• Encounter: Telehealth visit  
• Mental Status Examination (MSE):  
 – Appearance: Not fully assessable via telehealth  
 – Behavior: Cooperative and engaged  
 – Speech: Normal rate and rhythm (with a noted comment about speaking “around” her tongue)  
 – Mood: Reported as “good”  
 – Affect: Appropriate  
 – Thought Process: Logical, organized, and goal-directed  
 – Thought Content: No suicidal or homicidal ideation  
 – Cognition: Alert and oriented; coherent history provided  
 – Insight/Judgment: Good awareness regarding medication effects and side effects  
• Vital signs: Not documented

Assessment / Diagnosis

1. Attention-Deficit/Hyperactivity Disorder (ADHD)  
 – Managed with immediate-release Adderall 10mg twice daily.  
 – Patient reports good focus and task completion despite a mild waning effect after dose increases.

2. Anxiety  
 – Currently well-managed with improved control of thoughts noted by the patient.

3. New-onset Skin Picking Behavior  
 – Likely related to increased itchiness since starting Adderall, resulting in scalp picking and small red marks.  
 – Patient is actively working to discontinue this behavior.

4. Sleep Disturbance  
 – Patient is making an effort to correct her sleep schedule, although some residual sleepiness remains.

5. History of Restless Legs  
 – Long-standing condition since postpartum trauma; managed by appropriate timing of medication.

6. OCD Assessment  
 – Subclinical with a total score of 4/40. No significant obsessive or compulsive symptoms requiring intervention.

Plan / Treatment

1. Adderall immediate-release 10mg  
 – Continue current twice-daily regimen (morning and afternoon).  
 – Prescription refill sent to the pharmacy for availability on the 16th.

2. Extended-release Adderall Prior Authorization  
 – Continue efforts to obtain approval.  
 – Patient to bring insurance paperwork to the office for provider completion.

3. Fluoxetine  
 – Continue current dose (exact dose not specified; refills available per patient report).

4. Monitoring  
 – Monitor for continued scalp itching and skin picking behavior.  
 – Monitor ADHD symptoms and focus.  
 – Monitor anxiety levels and obsessive-compulsive tendencies (currently subclinical).  
 – Monitor sleep pattern and any further sleep disturbances.

5. Transition of Care  
 – Patient expressed interest in transferring ADHD/anxiety medication management to her PCP for cost-effectiveness reasons.  
 – Provider to see the patient one more time to ensure stability before transitioning; no additional monitoring requirements identified.

6. Follow-up  
 – Next appointment scheduled for November 4, 2025, at 2:30 PM via telehealth.

7. Patient Education  
 – Advised that controlled substance visits (Adderall) typically require follow-up every three months.  
 – Encouraged patient to contact the office if concerns arise prior to the scheduled appointment.

Additional Documentation

• Informed Consent:  
 – Patient participated knowingly in a telehealth visit.  
• Risk Assessment:  
 – No acute crisis or suicidal/homicidal ideation noted; stable psychiatric status.  
• Signature/Date:  
 – Documentation finalized on 10/07/2025 as part of the telehealth session.

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Quality Grade: High

Questions for Improvement:
• Would additional details regarding the patient’s past medical history (beyond the current psychiatric concerns) enhance the overall understanding and continuity of care?  
• Are there any other specific details about medication dosing or side effect management that should be documented further for future reference?

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Formatting

★★★★★4/5

The clinical note is thorough and follows a standardized template, capturing essential information for medical coding and claims processing. Key sections like HPI, ROS, assessment, and treatment plan are well-documented. However, there are areas that could be improved: the past medical history is missing details aside from the current psychiatric conditions, vital signs are not documented, and some medication details (such as the specific dose for Fluoxetine) are incomplete. These omissions slightly reduce the overall grading for coding completeness.

Queries

Could you confirm the exact dosage of Fluoxetine being administered? This detail would help ensure that the medication management and any relevant procedure documentation (if a separate medication management service was provided) are appropriately supported.

Could you clarify and provide a detailed past medical history, including any chronic conditions outside of the psychiatric concerns? This information is important for complete patient documentation (e.g., ICD-10 codes for comorbid chronic conditions).

The Fluoxetine dose is noted as 'continue current dose' without specification. Can you please confirm the exact dose of Fluoxetine the patient is taking for accurate medication billing and coding?

The note does not include any vital signs. Could you provide the patient's vital signs recorded during the telehealth session, if available? Vital signs are often necessary for a complete assessment (e.g., blood pressure, heart rate, weight).

Can you please clarify the specific subtype of ADHD diagnosed (e.g., predominantly inattentive type vs. combined type) for more precise ICD-10 coding? For instance, if predominantly inattentive then the code would be F90.0 with additional specification (e.g., F90.0).

Primary Diagnosis

95% Confidence

F90.9 ICD-10-CM i

The primary diagnosis is ADHD as indicated by the chief complaint 'Medication follow-up for ADHD and anxiety management' with detailed discussion on current Adderall management. F90.9 is used here for ADHD, unspecified subtype pending further clarification regarding subtype specificity.

Other Diagnosis

90% Confidence

G47.00 ICD-10-CM i

Sleep disturbance is documented with difficulty initiating sleep and altered sleep schedule. G47.00 for 'Insomnia, unspecified' is chosen to capture this sleep-related complaint.

95% Confidence

G25.81 ICD-10-CM i

The patient has a long-standing history of restless legs syndrome since postpartum trauma, which is managed by proper medication timing. G25.81 is used for restless legs syndrome.

90% Confidence

F63.1 ICD-10-CM i

New-onset skin picking behavior (excoriation disorder) is identified and is likely related to increased itchiness from Adderall. F63.1 represents skin picking (excoriation) disorder.

95% Confidence

F41.9 ICD-10-CM i

Anxiety disorder, unspecified is coded as F41.9 because the patient is being managed for anxiety with noted improvement, matching the visit's focus on medication follow-up for anxiety symptoms.

Procedures

Payer Rules Evaluation

No procedure codes were provided that correspond to the venous ablation or sclerotherapy procedures covered under the payer rules. The clinical note relates solely to psychiatric management (ADHD, anxiety, etc.) and does not include any lower‐extremity CVI/varicose vein treatment or documentation required by the rules (e.g., clinical presentation of limb symptoms, duplex scan details, CEAP class, or conservative therapy). Since the payer’s coverage criteria and mapping criteria specifically require both a relevant procedure code and a corresponding venous disease diagnosis, this claim does not meet the payer’s guidelines. Documentation such as imaging findings and conservative treatment records are completely absent. Therefore, no mapping exists between any procedure and diagnosis codes. Needs Clarification on whether this claim was intended for venous treatment or if it was erroneously submitted against these guidelines.