Encounter — Dorothy Wilson
New Patient | Dr. Michael Torres | 2/14/2026
Pipeline Status
Received
CDI Review
AI Coding
Compliance
Denial Check
Ready
Submitted
Clinical Note
Initial psychiatric evaluation, 60 minutes. Patient is a 52-year-old female referred for anxiety and depressive symptoms following workplace injury. History of generalized anxiety disorder for 10+ years, worsened in past 3 months. Reports persistent worry, muscle tension, irritability, sleep onset insomnia. PHQ-9: 11. GAD-7: 16. MSE: anxious affect, linear thought process, no psychotic features, no SI. Started buspirone 10mg BID. Discussed CBT referral. Return in 4 weeks.
Coding Results
ICD-10-CM Diagnoses
F41.1Generalized anxiety disorder
96%F33.0Major depressive disorder, recurrent, mild
84%G47.00Insomnia, unspecified
78%CPT Procedures
90792Psychiatric diagnostic evaluation with medical services
95%Details
- Patient
- Dorothy Wilson
- Provider
- Dr. Michael Torres
- Specialty
- Psychiatry
- Payer
- Aetna
- Visit Type
- New Patient
- Date of Service
- 2/14/2026
- Revenue Impact
- $287
CDI Review
QUERY
Findings (3)
- Diagnosis F33.0 (recurrent MDD) documented but note only describes current episode — missing prior episode documentation to support 'recurrent' specifier
- GAD-7 score supports anxiety diagnosis but PHQ-9 score of 11 is borderline — ensure clinical justification documented
- Missing documentation of medical necessity for 90792 vs 90791 — include physical exam components or medication management rationale
Compliance Check
79/ 100
Denial RiskHigh Risk
Payer: Aetna