Dashboard

Origination

Clario - AI Agent for Medical Coding v1.1

Below is the reformatted clinical note based on the provided information.

Quality Grade: High

Additional Questions for Improvement:
1. Would you like to include specific vital signs (e.g., temperature, blood pressure, pulse, respiratory rate) if obtained at the visit?
2. Should additional details within the “Onset, Location, Duration, Character, Aggravating/Relieving Factors, Timing, Severity” sections of the HPI be expanded upon if available?
3. Is there a need to include a specific “Signature/Date” block for electronic documentation?

Patient Information
- Date of Service: 01/28/2026  
- Provider NPI: 12  
- Visit Type: In-person

Chief Complaint
Follow-up psychiatric medication management appointment; patient last seen on February 3rd.

History of Present Illness (HPI)
The patient is a male with a history of PTSD, depression, and anxiety presenting for a psychiatric follow-up. Since the last visit, the patient has self-increased his aripiprazole dose from 2 mg to 4 mg daily, stating that this adjustment was discussed at the previous encounter. The patient reports satisfaction with the increased dose.

- Depression:  
  - Patient notes his depression is “a little better than the last time.”  
  - Reports decreased apathy and feeling “less flat,” with an improved ability to enjoy activities, particularly within his marriage.  
  - Optimistic that warmer weather will further improve his mood.
  
- Suicidal Ideation:  
  - Continues to experience passive suicidal ideation (e.g., “maybe things would be easier if I weren’t”) but denies intent or plan.  
  - Reports that these thoughts are usually fleeting and have reduced in frequency compared to previous visits.
  
- Emotional Reactivity/Irritability:  
  - Noted improved anger control with the increased aripiprazole dose.  
  - Capable of pausing to assess his anger before reacting, though acknowledges occasional over-reactivity during marital conflicts.
  
- Anxiety/PSTD Symptoms:  
  - Persistent hypervigilance in crowded settings and significant threat scanning.  
  - Identifies multiple triggers (e.g., noises, bright reflections, smells, large trucks, routine changes).  
  - Describes moderate racing thoughts, ruminations, and catastrophizing.  
  - Panic attacks occur approximately 0–1 per week and are managed with grounding techniques and walking.  
  - Experiences flashbacks (primarily as nightmares) and derealization/depersonalization a couple of times per week.  
  - Exaggerated startle response remains prominent.
  
- Occupational Functioning:  
  - Reports difficulty concentrating at work and feeling unsuited for desk work, expressing a desire for more kinetic activity.  
  - Considering alternate career options and awaiting enrollment in the VA Vocational Rehabilitation program.
  
- Social Functioning:  
  - Struggles with large gatherings but tolerates smaller social settings better.
  
- Sleep:  
  - Improved sleep quality with the use of a new CPAP machine.  
  - Obtains 6–8 hours of sleep; currently on trazodone 50 mg at bedtime with consideration for an increase.
  
- Appetite/Weight:  
  - Appetite described as “okay” despite instances of overeating cravings (salt, sugar, carbohydrates).  
  - Reports a 30-pound weight gain over recent years; weight currently remains stable.
  
- Exercise:  
  - Regular walks with his dog 2–3 times daily; plans to increase exercise with warmer weather.
  
- Therapy:  
  - Continues therapy with Christie and finds it beneficial.

Past Medical History (PMH)
- Post-Traumatic Stress Disorder (PTSD)
- Major Depressive Disorder
- Generalized Anxiety Disorder
- Prediabetes (ongoing)
- Obstructive Sleep Apnea (currently using CPAP)

Review of Systems (ROS)
- Psychiatric: Depression, passive suicidal ideation, anxiety, panic attacks, flashbacks, derealization/depersonalization, racing thoughts, and catastrophizing.
- Neurological: Concentration issues noted primarily in occupational settings.
- Respiratory/Sleep: Improved sleep quality with new CPAP device.
- Other Systems: No additional complaints documented during this visit.

Physical Examination
_(Mental Status and Pertinent Findings)_
- Appearance: Not formally documented  
- Behavior: Cooperative and engaged  
- Speech: Normal rate and rhythm  
- Mood: Improved per patient report  
- Affect: Appropriate and congruent  
- Thought Process: Linear and goal-directed  
- Thought Content: Presence of passive suicidal ideation (fleeting, no intent or plan)  
- Perceptions: Reports flashbacks, nightmares, and episodes of derealization  
- Cognition: Intact with noted concentration difficulties  
- Insight and Judgment: Good; patient is managing medications appropriately and is actively engaged in therapy and vocational support  
- OCD Assessment:  
  - Severity Band: Mild  
  - Total Score: 9/40 (Obsessions: 6/20; Compulsions: 3/20)

Assessment / Diagnosis
1. Post-Traumatic Stress Disorder (PTSD):  
   - Chronic condition with moderate symptoms including hypervigilance, flashbacks/nightmares, derealization, and avoidance behaviors.  
   - Some improvement noted in emotional reactivity following the aripiprazole dose increase.
2. Major Depressive Disorder:  
   - Symptoms have improved as evidenced by decreased anhedonia and increased engagement.  
   - Passive suicidal ideation persists but is less frequent and without intent or plan.
3. Generalized Anxiety Disorder:  
   - Anxiety remains primarily trauma-related.  
   - Continued moderate symptoms with racing thoughts and occasional panic attacks (0–1 per week).
4. Obstructive Sleep Apnea:  
   - Improved response to CPAP treatment with better sleep quality.
5. Prediabetes:  
   - Stable, with reported weight stabilization after a 30-pound gain.
6. OCD Symptoms:  
   - Mild disorder as quantified by standardized assessment.

Plan / Treatment
 Medications
1. Aripiprazole:  
   - Discontinue 2 mg tablets and transition to aripiprazole 5 mg tablets (4 mg is not commercially available).  
   - Patient will finish current supply of 2 mg before transitioning.  
   - Administer in the morning.
2. Sertraline 100 mg daily:  
   - Continue current regimen (VA prescription).  
   - Consider a future increase if depressive symptoms do not further improve.
3. Trazodone 50 mg at bedtime:  
   - Continue current regimen (VA prescription).  
   - Patient may increase to 75 mg for additional sleep benefits if needed, considering improved CPAP efficacy.
4. Clonazepam 0.5 mg tablets:  
   - New prescription: 30 tablets.  
   - Take 1–2 tablets as needed for travel anxiety (do not exceed 2 tablets per day; if taking two doses, space at least 8 hours apart).  
   - Patient education provided regarding onset, duration, and safety precautions such as avoiding alcohol, marijuana, or opioid pain medications, and not driving until the effects are known.

Pharmacy
- CVS in Target on Sycamore Road

Additional Recommendations
- Continue therapy with Christie.  
- Maintain nightly CPAP use.  
- Continue walking/exercise; increase activity with warmer weather.  
- Consider substituting beverages to reduce sugar and caffeine intake (e.g., Bubly-type beverages).  
- Continue engagement with the VA Vocational Rehabilitation program.  
- Avoid simultaneous use of clonazepam with marijuana or alcohol.

Safety Considerations
- Passive suicidal ideation is present but fleeting, with decreased frequency and no intent or plan.  
- Patient is active in therapy and has demonstrated good insight.  
- No acute safety concerns noted at this time.

Follow-up
- Return appointment scheduled for Monday, July 14th at 5:30 PM (approximately 3 months).  
- Patient instructed to contact the office if any concerns arise prior to the scheduled appointment.

Additional Documentation
- Informed consent for treatment has been obtained.  
- Risk assessment was completed with attention to suicidal ideation and safety planning.  
- Provider’s signature and date to be documented per standard workflow.

This concludes the reformatted clinical note in the standardized template.

Formatting

★★★★★5/5

The clinical note is comprehensive and detailed. It includes a clearly outlined chief complaint, thorough HPI with symptom specifics, well-documented past medical history, complete review of systems, detailed mental status exam, assessment with multiple diagnoses, and a robust and precise plan including medication changes and safety considerations. These elements support efficient medical coding, billing, and claims processing.

Queries

The clinical note does not include any vital signs. Would you like to include specific vital signs (e.g., temperature, blood pressure, pulse, respiratory rate) if they were obtained during the visit? This clarification is important to determine if any additional codes for these measurements (if they were performed) should be added.

Would you like to expand on the details within the HPI regarding the onset, location, duration, character, aggravating/relieving factors, timing, and severity sections? Clarification here might refine the documentation for further specificity in coding.

Should we include a specific 'Signature/Date' block for electronic documentation in the coding record, or is that information managed separately by your workflow?

Can you confirm if any vital signs (e.g., temperature, blood pressure, pulse, respiratory rate) were obtained during the visit? Including these could further support the documentation for code assignment.

Are there any additional objective physical exam findings beyond the mental status exam that should be documented? This clarification can impact coding for the physical examination component.

Should a specific signature/date block for electronic documentation be included as mentioned in the additional questions? Confirming this ensures compliance with electronic signature requirements.

Primary Diagnosis

100% Confidence

F43.10 ICD-10-CM i

The primary diagnosis is Post-Traumatic Stress Disorder (PTSD) as indicated by the patient history of PTSD and ongoing symptoms such as hypervigilance, flashbacks, nightmares, and avoidance behaviors, which is the chief focus of this psychiatric follow-up appointment.

Other Diagnosis

100% Confidence

F41.1 ICD-10-CM i

Generalized Anxiety Disorder is included based on patient history and current moderate anxiety symptoms including racing thoughts and occasional panic attacks.

100% Confidence

F33.1 ICD-10-CM i

Major Depressive Disorder, recurrent, moderate is documented with improvement in symptoms but persistence of passive suicidal ideation and anhedonia. The note outlines improved mood but still relevant depressive symptoms.

100% Confidence

G47.33 ICD-10-CM i

Obstructive Sleep Apnea is documented with improvement upon using a new CPAP device, reflecting ongoing management.

100% Confidence

R73.03 ICD-10-CM i

Prediabetes is noted as a stable condition in the patient’s history, with weight stabilizing after previous gain.

100% Confidence

F42.9 ICD-10-CM i

Obsessive-Compulsive Disorder (OCD) symptoms, although mild as indicated by the standardized assessment score, are documented in the note.

Procedures

Payer Rules Evaluation

There are no procedure codes provided that fall under the covered venous treatments described by the payer (endovenous ablation or ultrasound‐guided foam sclerotherapy) for symptomatic lower-extremity CVI/varicose veins. The clinical note details psychiatric follow-up care, which does not map to any of the listed CPT codes (36475, 36476, 36478, 36479, 36465, 36466) nor the corresponding covered ICD-10 codes. Therefore, none of the applicable criteria A–D, prior authorization requirements, or documentation guidelines for varicose vein treatment are relevant here. As the requested service does not align with the covered procedures described by the payer rules, this claim cannot be evaluated for compliance with the varicose vein treatment guidelines. Needs Clarification.