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Coding Assignment 

History of Present Illness: The patient is a 27-year-old female here today for a follow-up visit for depression and anxiety. This is a known condition and I have been treating the patient for over 1 year. She is not accompanied by anyone else today. She reports some increased additional stress to her previous symptoms. She is having some difficulty at work but reports she feels like she is coping well. She has minimal situational sadness but increased anxiety with stress. Denies any suicidal or homicidal ideations. 

Past Family/Social History: n/a Review of Systems: no sadness, anxiety, or irritability presently 

Physical Exam: 

Constitution: appearance WNL, appropriate dress, appears stated age

Psych: speech normal rate and tone; thought content; no SI/HI or psychotic symptoms; associations: intact; orientation x3; mood and affect: euthymic and appropriate; Judgment and insight: good 

Assessment: 

______ Depression, stable 
______ Anxiety, slightly increased from last visit 

Plan: 

Stable on SSRI for depression – continue on same dose 
Anxiety has increase so we will give Buspar 10 mg BID in addition to SSRI 
Follow up in 4 weeks 
Total time spent 15 minutes 

CPT_________________ 

 

SCIENCE
HEALTH SCIENCE
NURSING

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