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Clario - AI Agent for Medical Coding v1.1

Below is the reformatted clinical note based on the provided template:

Patient Information
- Age/Sex: 26-year-old male  
- Marital Status: Married to Carolyn  
- Occupation: Police officer (currently assigned as canine officer; permanent second shift 2:45 PM–11 PM; on-call status)  
- Living Situation: Resides in Mount Prospect with his wife; recently purchased his first home

Chief Complaint
Patient presents for a new patient psychiatric evaluation stating he is "at the point now where I need definite help" with time management, focus, and feeling as though he is at a "breaking point."

History of Present Illness (HPI)
- Onset: Symptoms have been present for "several months at least" with worsening recognition "several weeks ago."  
- Location: Impacts both home and work environments.  
- Duration: Chronic symptoms with recent acute exacerbation; specific episodes occur multiple times a week.  
- Character:  
  - Time management difficulties with disrupted schedules on days off  
  - Intermittent speech difficulties, described as "mind and mouth are disconnected"  
  - Rumination or obsessive thoughts that can last "all day"  
  - Perfectionism that leads to overwhelm when tasks do not match his exact standards  
  - Emotional dysregulation with episodes of anger, frustration, and shutdown  
- Aggravating Factors:  
  - Increased demands at work (new supervisory structure, on-call status)  
  - Household stress (recent move, canine behavioral issues, scheduling conflicts with wife’s work)  
  - Difficulty with decision-making (fear of upsetting his wife)  
- Relieving Factors:  
  - Engaging therapy (prior individual and couples sessions) provided temporary relief  
  - Structured routines have been challenging to maintain  
- Timing:  
  - More noticeable on days off and during periods of high work and home demands  
  - Shutdown episodes can last until the next sleep cycle  
- Severity:  
  - Functional impairment impacting work performance (long report completion times, confrontation with supervisors/coworkers) and home life (diminished household management, social withdrawal)  
- Narrative:  
  The patient reports chronic challenges with time management, focus, and emotional regulation that have progressively worsened over the past several months. Initial impacts were noted in his personal relationships and have now extended to his professional life. He describes a persistent internal struggle with ruminative thoughts and an overwhelming need to control tasks perfectly. Sleep disturbances, including sleep apnea and episodes of sleepwalking, further compound daily exhaustion. His symptoms are accompanied by anxiety that has led him to seek definitive help through a psychiatric evaluation.

Past Medical History (PMH)
- Medical Conditions:  
  - Sleep apnea (diagnosed)  
  - Degenerative disc disease (back pain)  
  - History of deviated septum with prior septoplasty and turbinate reduction (suboptimal outcome)  
  - History of tonsillectomy at age 19  
  - Chronic pain: Feet, back, and posture-related (uses orthotics; physical therapy; prescribed stretching app)  
  - History of frequent strep throat infections during youth  
  - Barotrauma during military deployment with near loss of consciousness  
  - Multiple concussions from sports and youth activities (last concussion in 8th grade/high school; one with loss of consciousness requiring ER evaluation)  
  - Various injuries during military service (aircraft pressurization, physically demanding work)  
- Past Psychiatric History:  
  - Previous individual therapy (approximately 2 years ago)  
  - Couples therapy (approximately 1 year ago)  
  - No formal psychiatric diagnoses previously  
  - History of pornography addiction addressed in therapy 2-3 years ago  
- Current Medications:  
  - Daily multivitamin  
  - Whey protein powder (occasionally)  
  - Nasal spray (daily, for sleep apnea)  
- Allergies:  
  - Amoxicillin (reaction during childhood)  
  - No issues with anesthesia

Review of Systems (ROS)
- Constitutional:  
  - Reports daily chronic pain in feet and back (worst days rated as 6-7/10)  
  - Denies fever or significant weight changes  
- HEENT:  
  - History of deviated septum and prior septoplasty  
- Cardiovascular:  
  - Denies chest pain or palpitations  
- Respiratory:  
  - Sleep apnea present  
- Gastrointestinal:  
  - Appetite affected by forgetting to eat; eats approximately twice daily instead of the desired three times  
- Neurological:  
  - Reports intermittent speech difficulties and concentration problems  
- Psychiatric:  
  - Anxiety, ruminative/obsessive thoughts, perfectionism, emotional dysregulation, social withdrawal, reduced motivation  
  - Reports difficulty with decision-making  
- Musculoskeletal:  
  - Chronic pain in feet and back, degenerative disc disease  
- Sleep:  
  - Inconsistent sleep schedule due to work  
  - Experiences significant snoring, sleep talking, sleepwalking, and occasional nightmares; wakes feeling exhausted despite 8 hours of sleep

Physical Examination
- General Appearance:  
  - Age-appropriate, appropriately groomed  
- Behavior:  
  - Cooperative and engaged; good eye contact  
  - Wife present providing collateral information  
- Speech:  
  - Normal rate and rhythm during session  
  - Patient reports intermittent difficulties with speech/articulation outside of session  
- Mood and Affect:  
  - Mood reported as "at a breaking point"  
  - Affect is appropriate to content with full range; displays frustration and distress when discussing symptoms  
- Thought Process and Content:  
  - Thought process is linear and goal-directed with occasional tangential responses  
  - Denies suicidal or homicidal ideation; no delusions, hallucinations; endorses ruminative and obsessive thoughts  
- Cognition:  
  - Alert and oriented; insight and judgment fair  
- Memory:  
  - Reports difficulties with memory for appointments and obligations  
- ASRS Screening:  
  - Trouble wrapping up final details of projects: Often  
  - Difficulty organizing tasks: Often  
  - Avoids or delays tasks requiring a lot of thought: Often  
  - Fidgeting or squirming when sitting for long periods: Often  
  - Feeling overly active or driven by a motor: Often

Assessment / Diagnosis
1. Generalized Anxiety Disorder  
   - Excessive worry, rumination, difficulty controlling thoughts, physical manifestations of anxiety (anger, shutdown episodes), reassurance-seeking behavior, and clear functional impairment. Symptoms have been present for several months with recent exacerbation.

2. Attention-Deficit/Hyperactivity Disorder, provisional  
   - Presentation includes inattention (difficulty with task completion, time management, memory lapses), hyperactivity (restlessness, fidgeting), and impulsivity. Onset appears in later adulthood with performance issues at work and home. Further evaluation planned after initial management of anxiety.

3. Sleep-related Concerns  
   - Diagnosed sleep apnea; significant sleep disturbances (snoring, sleep talking, sleepwalking, nightmares) affect daytime energy and performance.

4. Chronic Pain  
   - Ongoing issues related to degenerative disc disease and foot pain contributing to overall mood and functional impairment.

Clinical Reasoning:  
The presentation is most consistent with a primary anxiety disorder that is impacting cognitive functions and daily routines. The provisional ADHD diagnosis is considered in light of inattention and hyperactivity symptoms emerging in a context of worsening anxiety. Sleep disturbances and chronic pain also contribute to the patient’s overall functional impairment.

Plan / Treatment
1. Pharmacotherapy:  
   - Begin Lexapro (escitalopram) 10 mg daily  
     - Rationale: First-line treatment for generalized anxiety disorder. It is expected to improve anxiety without exacerbating potential ADHD symptoms.
   - Prescription sent to Walgreens on East Rand Road.  
   - Education provided regarding daily dosing consistency and the delayed onset of therapeutic benefits over several weeks.

2. Therapy Referral:  
   - Referral for individual therapy with an in-house therapist to help develop coping strategies and address ruminative/perfectionistic thought patterns.  
   - External referral options will be provided if scheduling conflicts arise.

3. Diagnostic Considerations:  
   - Further assessment for ADHD will be conducted at a follow-up appointment once anxiety symptoms are better managed.  
   - Stimulant medications are deferred at this time due to the risk of exacerbating anxiety.

4. Sleep Management:  
   - Discussed sleep quality issues related to diagnosed sleep apnea and inadequate results from previous septoplasty.  
   - Patient encouraged to follow up with ENT regarding potential further interventions for sleep apnea.

5. Follow-up:  
   - A return appointment is scheduled in 4 weeks (August 11th at 10:30 AM) to assess medication efficacy and tolerability.  
   - Patient instructed to contact the office with any concerns prior to the scheduled follow-up.

6. Safety Assessment:  
   - Patient denies current suicidal ideation, homicidal ideation, or self-harm thoughts.  
   - No acute safety concerns noted at this time.

Additional Documentation
- Informed Consent: Informed consent for treatment was discussed and obtained.  
- Risk Assessment: Patient denies any current suicidal or homicidal ideation; risk assessment deemed low at this time.  
- Signature/Date:  
  - Clinician Signature: __________________________  
  - Date: __________________________

Quality Grade: A

Are there any additional details or modifications you would like to see in this formatted note?

Formatting

★★★★★5/5

The clinical note is exceptionally detailed and well-organized, covering all essential sections including Patient Information, Chief Complaint, HPI, PMH, ROS, Physical Examination, Assessment/Diagnosis, and Plan/Treatment. Each section contains the specific details needed for precise medical coding, billing, and claims processing. The note clearly documents symptoms, duration, severity, medication instructions, follow-up plans, and safety assessments which are crucial for determining codes and billing procedures.

Queries

The provided notes only contain formatting markers ('-_-_-_-') and instructions regarding coding for wounds and E&M services. To assign accurate CPT codes for each treated wound and possibly an E&M code, could you please provide additional clinical details? Specifically, we need information about the number of wounds treated, the procedures performed on each wound (including measurements if applicable), and whether any evaluation and management office visit was conducted during this encounter. This clarification will help us determine if a procedure code is applicable for each wound (or none if no treatment was documented), and if an E&M code should be added (e.g., CPT 99213 or similar) based on the visit details. The clarification is required to ensure proper coding according to the guidelines [Procedure Code: Wound Treatment; E&M: Office Visit].

Could you please confirm the final signed documentation, including the printed name and date for the clinician’s signature section? (This is important for ensuring legal compliance and proper audit trail for codes such as 99204 for a new patient psychiatric evaluation.)

Can you clarify if any formal evaluations or standardized assessments (beyond the ASRS screening noted) are planned or have been ordered for the provisional ADHD diagnosis? (This helps in assigning appropriate codes like 314.00 for ADHD evaluation if needed.)

Primary Diagnosis

95% Confidence

F41.1 ICD-10-CM i

The primary complaint is the patient’s overwhelming anxiety, worry, and functional impairment impacting his work and personal life, which aligns with Generalized Anxiety Disorder (F41.1). This was explicitly documented in the Assessment as the chief issue for the visit.

Other Diagnosis

90% Confidence

G89.29 ICD-10-CM i

Chronic pain related to degenerative disc disease and musculoskeletal discomfort is documented in the patient’s history and noted to contribute to overall impairment. G89.29, which denotes other chronic pain, is chosen to reflect this condition.

90% Confidence

F90.9 ICD-10-CM i

The provisional diagnosis of Attention-Deficit/Hyperactivity Disorder is noted due to inattention, time management issues, and hyperactivity symptoms in the context of the patient’s functional impairment. F90.9 is used as it represents ADHD, unspecified.

95% Confidence

G47.33 ICD-10-CM i

Sleep-related concerns are addressed under obstructive sleep apnea, as mentioned in both the PMH and the assessment. G47.33 is specific for obstructive sleep apnea in adults.

Procedures

95% Confidence

90791 CPT i

A comprehensive new patient psychiatric evaluation was performed, which matches CPT code 90791. This code is specifically used for psychiatric diagnostic evaluations without associated medical services.

Performed By Psychiatrist/Clinician
Modifier Value

Performed On Date of Visit
Units Or Days 1

Schedule Unknown

Reason New patient evaluation

Payer Rules Evaluation

Procedure code 90791, a psychiatric diagnostic evaluation, was paired with diagnosis codes for generalized anxiety disorder (F41.1), ADHD (F90.9), sleep apnea (G47.33), and chronic pain (G89.29). However, the payer’s coverage rules described pertain exclusively to endovenous ablation and ultrasound-guided foam sclerotherapy for symptomatic lower‐extremity CVI/varicose veins. The required clinical criteria (symptoms such as limb aching, skin changes, etc.), imaging criteria, CEAP classification, and documentation of conservative therapy are not relevant to a psychiatric evaluation. There is no mapping within the payer rules linking 90791 to any of the covered venous treatment criteria. In addition, required documentation and prior authorization conditions stated in the venous treatment guidelines are not provided. As a result, this procedure and diagnosis pairing does not comply with the payer’s specific coverage rules.